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CHARLES WHITE 

OF Manchester (1728-1813) 



AND 



THE ARREST OF PUERPERAL FEVER 




CHARLES WHITE, F.R.S. 

From the bust by E. G. Papworth, in the Royal Infirmary, Manchester, 
presented by Charles Jordan, 1886. 



Photograph by fVarxvick Brookes, 



HGvO 

CHARLES WHITE 

OF Manchester {1728-18 13), 

AND 

THE ARREST OF PUERPERAL FEVER 

being the 

Lloyd Roberts Lecture 

Manchester Royal Infirmary 

1 921 



BY 

Jf'GEORGE ADAMI, 

C.B.E., M.D., F.R.S. 

V ice-Chancellor of the University oj Liverpool, 



WITH WHICH ARE REPRINTED 

CHARLES WHITE'S PUBLISHED WRITINGS 
UPON PUERPERAL FEVER 



-> 






THE UNIVERSITY PRESS OF LIVERPOOL LTD. 

HODDER AND STOUGHTON LTD., LONDON 

1922 



IJ 



0* 



Made and Printed in Great Britain by C. Tinling & Co., Ltd. 
53, Victoria Street, Liverpool, 
J V, and at London and Prescot. 



TABLE OF CONTENTS 



I. Introductory 

II. Charles White, the Pioneer . 

III. Sinclair and Semmelweis 

IV. White's Teaching .... 
V. The Application of White's Teaching 

VI. The Teaching of Semmelweis . 

VII. The Modern Teaching . 

VIII. The Manchester School and its Future 



PAGE 

7 
II 

H 

20 
26 

31 
36 

43 



Charles White's Writings upon Puerperal Fever 
A Treatise upon the Management, etc. 

Chapter I . 51 

Chapter VI 65 

Appendix to the Second Edition .... 91 



ILLUSTRATIONS 

The Bust of Charles White at the Royal Infirmary 

Frontispiece 

Reproduction of Ward's Mezzotint of Charles 

White Facing 49 

Reproduction of Title Page of the First Edition 

OF the Management, etc. .... 49 

Reproduction of Title Page of the Appendix to 

the Second Edition 91 



CHARLES WHITE 

OF Manchester (1728-1813), 

AND 

THE ARREST OF PUERPERAL FEVER 

I 

Introductory 

By his Will, the late Dr. David Lloyd Roberts, who 
died 27th September, 1920, at the ripe age of 86, left 
to the Manchester Royal Infirmary, with which he had 
been associated for thirty-five years, the sum of ^3,000 
and — to quote the Will — ' an additional sum of j^5oo 
upon trust to invest the same and to apply the income 
each year in payment of an honorarium for the 
delivery of a lecture (to be called the " Lloyd Roberts 
Lecture ") on any subject of Medical or Scientific 
interest, each Lecture to be delivered by such person 
in such place and to such persons and subject to such 
regulations as the Institution administering the trust 
legacy may in its absolute discretion determine.' 

It is in accordance with that bequest that I was 
called upon to deliver the first of the Lloyd Roberts 
Lectures. As an old student of the Manchester 
Medical School and house physician of the Royal 



8 INTRODUCTORY 

Infirmary ; as one who was a student under Lloyd 
Roberts ; and perhaps more especially as one who is 
neither an obstetrician nor a gynaecologist, I could 
not but appreciate greatly the honour conferred upon 
me in asking me to inaugurate the series of lectures 
which will keep green the name and fame of one who 
in his time was a leading Lancashire obstetrician and 
gynaecologist. Furthermore, as an old student it 
touched me closely to be thus remembered ; as one who 
knew Lloyd Roberts it was good to undertake this pious 
duty, and in the third place — although I cannot say 
for certain that this is the case in the present instance — 
often it happens that he who beholds things from out- 
side sees more clearly the trend of affairs than those 
who are in the very midst of them. Wherefore 
possibly I who had for so long been away from 
Manchester and indeed from medical practice, might 
be able to place before the practitioners of Manchester 
and district, with a certain amount of clarity, what 
the outer world thinks of matters obstetrical and 
gynaecological here in Manchester. 

Lloyd Roberts was indeed a personality — a humorist, 
in the sense of Ben Jonson. He was himself, and 
like no one else in the profession : at once blunt and 
sharp, as poignantly direct as he could be quizzically 
evasive ; a Welshman, with all that that implies, but 
before all a Lancashire man, rough in manner and in 
matter, yet loving and surrounding himself with 
objects of beauty ; full of wise saws and homely 
wisdom, so that his sayings have become proverbial ; 



LLOYD ROBERTS 9 

Doric in speech, yet given to the best in literature, 
rejoicing above all in the choice phrasing and noble 
language of the author of ' ReHgio Medici,' of which 
v^ork, indeed, he edited a well-known edition ; devoted 
to his profession yet shrewd in business — some would 
say to the limit of shrewdness ; careful in small 
things, yet careless of still smaller — fashions, for 
example ; generous on a large scale, as shown by his 
Will, and not incapable of perversity ; a good — or some 
would say a wicked — hater. It was the strength and 
originality of his character, coupled wdth his knowledge 
of humanity, and particularly of femininity, rather 
than his contributions to the advance of his subject 
and their originality, that impressed the student, and 
for long years gave him his very real influence and 
standing among his colleagues. What he wrote was 
clear in expression and sound in doctrine, even though, 
as we students thought in the 'eighties, that doctrine 
was not quite the latest. 

It is marvellous what mixtures we mortals be : it 
would be difficult to meet with a quainter, more 
delightful medley than that of which Lloyd Roberts 
was composed. One's memory of him is, as it were, 
of a ripe old Burgundy that must have been rough 
and strong and heady in its youth, that had mellowed 
until full of aromatic ethers but that, with all its 
bouquet, still smacked of the soil. 

It seemed to me that I could not do better than 
inaugurate this series of lectures with an historical 
study, taking as my subject part of that which Lloyd 



10 INTRODUCTORY 

Roberts made the topic of his last important address 
when President of the Section of Obstetrics and 
Gynaecology at the Manchester meeting of the British 
Medical Association in 1902, namely, the Manchester 
School of Obstetrics and Gynaecology, and its rise. 
I am indebted to the Journal of Obstetrics and 
Gynaecology of the British Empire for permission 
to re-publish this lecture in book form. In so doing 
I have subjected it to slight revision and have added 
certain notes. It seemed, further, that it might 
interest readers to be able to refer to Charles White's 
full statement regarding Puerperal Fever ; I have thus 
reprinted from the first edition of his w^ork on the 
Management of Pregnant and Lying-in Women the 
chapters on the causes and symptoms and on the 
treatment of Puerperal Fever, and certain paragraphs 
from other chapters directly bearing upon the matter 
of the lecture, along v^ith the Appendix to the second 
edition of 1777 which contains so much of importance 
that I have reproduced it in full. This, I find, was 
also published separately for the benefit, I take it, of 
those who possessed the first edition. I have 
collated all the editions published before 1800 and find 
that they are identical save (i) for minor variations in 
printing, (2) for the Appendix here given and (3) for 
the paragraph regarding antiseptic injections added to 
the third edition of 1784 and cited by me on p. 22.^ 

I. I am greatly indebted to my cousin, Dr. E. Bosdin Leech, for 
providing me with these editions as also for the photograph of the bust 
of Charles White which forms the frontispiece. 



THE MANCHESTER SCHOOL OF MEDICINE ii 

II 

Charles White, the Pioneer 

' Too OFTEN,' said Lloyd Roberts in his opening remarks 
at the meeting in 1902, ' do we forget those who first 
force their way along unknown paths which in the 
future become well-frequented thoroughfares ; who 
first point out to what important ends such paths 
may lead ; who persevere through weal and through 
woe, through opposition and calumny ; who never 
falter in their struggle along the paths they see dimly 
traced before them, or even when they must needs 
grope blindly along the absolutely unknown ; too 
often is the honour due to these pioneers pushed into 
the limbo of obscurity by the very weight and magni- 
tude of the chain, the initial links of which they 
themselves had helped to forge.' 

It is but lost labour to attempt to develop either 
a University or a Medical School without local pride 
and local patriotism, and to establish that pride and 
that patriotism before all things it is necessary to 
build up and cherish the history and traditions of the 
school. What is more, in these days, with the ever- 
increasing burden of new knowledge and new develop- 
ments that have to be mastered, for right thinking and 
the appraisal of values, in fact for the pigeon-holeing 
of that new knowledge in its proper place in the brain, 
it is increasingly essential for teachers as well as for 
the taught to gain and to possess — if I may be permitted 
to mix metaphors — a correct historical perspective. 



12 CHARLES WHITE: THE PIONEER 

In the Manchester School of Medicine there is no 
department that has a finer tradition and history than 
that of Gynaecology and Obstetrics. Manchester 
may well be proud of the great new-old Infirmary, of 
its new and commodious installation, of its old renown. 
But I would have you remember that the man who was 
responsible for its foundation will go down to history 
as a great obstetrician, nay as one of the greatest — 
Charles White, the friend and fellow-student of 
John Hunter^ : Charles White the distinguished surgeon 
who first excised the head of the humerus and both 
articular surfaces of the joint for caries, in place of 
amputation, who used dried sponge to arrest haemorr- 
hage a century and more before Sir Victor Horsley : the 
* Father of Anthropometry.' ^ 

In 1752, White, before he was twenty- four years of 
age, with the financial support of Mr. Joseph Bancroft, 
rented a house and converted it into a small hospital, 
the first public hospital established in Manchester, 
and carried it on with such success that in 1755 it gave 
place to a larger new Infirmary of 40 beds with the 
founder as chief surgeon, a position he held for 38 years. 

1. After serving as apprentice to his father, White, at the age of 
twenty, went to London and there attended the course of lectures 
upon Anatomy given by William Hunter, the elder of the two great 
brothers. It was this same autumn that John joined his brother, and 
not merely attended the lectures but helped in preparing the illustrative 
dissections. At these lectures began a friendship between Charles 
White and John Hunter which was destined to continue through life. 
It is interesting to note that from London White went for a short 
period to Edinburgh, where already the first beginnings of a school of 
obstetrics were showing themselves. 

2. See Brockbank, The Honorary Medical Staff of the Manchester 
Infirmary. Manchester : At the University Press, 1904. p. 49. 



HIS MEMORIAL TABLET 13 

White was thus the creator of the Royal Infirmary. 
His bust in marble forms one of its treasures. In 
like manner he was the moving spirit in the establish- 
ment of the Lying-in charity which has developed into 
that great institution, St. Mary's Hospital. White 
also took an active part in 1783 in the establishment of 
the first College for advanced education in the 
provinces outside the old Universities — the College 
of Arts and Sciences — in which he and his son delivered 
the courses of lectures in Anatomy. 

I am not going to detail to you the life of Charles 
White : has it not been studied and described in late 
years by Lloyd Roberts, CuUingworth, Whitehead, and 
Brockbank ? The medical history of Manchester may 
well be said to begin with him. Not but that I am 
strongly tempted, for from my boyhood, when I sat 
Sunday after Sunday under his memorial tablet in the 
old Parish Church at Ashton-upon-Mersey, Charles 
White has been one of my heroes. In those early days 
I could only imagine things about one so distinguished 
that his merits were conveyed to posterity in marble, 
and could but chew the cud of enjoyment over the 
Johnsonian periodicity of the epitaph of the 

Member of the Corporation of Surgeons and 

Fellow of the Royal Society 

who 

after rendering himself eminent in his Profession 

for the space of sixty years 

by a Dexterity and Extent of Knowledge 

scarce exceeded by any of his Cotemporaries 

retired 

to the Enjoyment of rural and domestic Felicity 

in the Society of his Family and Friends 

at Sale within this Parish 

He died on the 20th of February, 181 3, aged 84. 



14 SINCLAIR AND SEMMELWEIS 

It may have been a bad model, but I loved the rich roll 
of that ' rural and domestic Felicity,' and as I grew 
towards youth I tried to hunt out fuller information 
about him at the Chetham Library, the Reference 
Library, and elsewhere, with little success. I did not 
know how to hunt libraries in those days, and there 
were few to direct me, few also who after sixty years 
or so knew anything about him. It was only in after 
years, through the late Professor Cullingworth, that I 
obtained full knowledge of his life's work. 

Ill 

SitTclair and Semmelweis 

What I want to impress upon you is that great as is 
Manchester's debt to him, he will be remembered in 
medical history for his work as an obstetrician. I have 
already referred to the importance of a proper historical 
perspective for teachers as well as for students. You 
may imagine my disgust a few years ago when a certain 
able knight, now no more, who held the Chair of 
Obstetrics and Gynaecology in the University of 
Manchester, published a very complete life of the 
Hungarian Professor of Obstetrics, Semmelweis ; ^ 
published it that he might establish among English- 
speaking people a due recognition of Semmelweis's 
position as the pioneer in establishing the true nature of 
puerperal fever and the right means of prophylaxis ; and 

I. Semmelweis, I. P., his Life and Doctrine ; a chapter in the 
History of Medicine, by Sir William J. Sinclair, M.A., M.D. 
Manchester : At the University Press, 1909. 



SINCLAIR AND CHARLES WHITE 15 

claiming for him that ' in the whole history of Medicine 
we find a clear record of only two discoveries of the 
highest importance in producing direct and immediate 
blessings to the human race by the saving of life and 
the prevention of suffering,' ^ those namely, of Edward 
Jenner and Ignaz Phillip Semmelweis. 

Such a statement is that of a special pleader. What 
about the discovery of anaesthetics, or the work of 
Pasteur and of Lister, or the discovery of Diphtheria 
antitoxin ? Were Sir William alive I might speak 
more strongly. Nevertheless, when the head of a school 
belittles the founder of that school the maxim ' De 
mortuis nil nisi bonum ' does not apply. Yet let me 
assure you that it is not that I want to attack Sinclair — 
far from it ! — but, in order to give honour where honour 
is due, it is essential that Sinclair's work should be 
criticised and corrected. The whole volume, indeed, 
is one of unreasoning advocacy, in which, in order to 
establish his point the author throughout minimises the 
notable work accomplished by British obstetricians 
long years before Semmelweis came on the scene, and 
in particular so minimises the work of Charles White 
as to make it evident that his references are second-hand, 
that he. Professor of Obstetrics in Manchester, had not 
been familiar with that remarkable work of a Manchester 
obstetrician, ' The Management of Pregnant and 
Lying-in Women, and the means of curing, more 
especially of preventing, the principal disorders to 
which they are liable.' 

I. Sinclair, Sir W. loc. cit : p. I. 



i6 KIRKLAND 

This is a treatise that in its day had a remarkable 
influence. First pubHshed in 1773, within twenty 
years there were no less than five editions. The book 
was translated into French in the year of its first 
publication and into German within two years, and 
was reprinted at Worcester, Massachusetts, in 1793. 
Of all men, it may be said, Sinclair should have had 
knowledge of this work. Had he been famiHar with 
it he could not have given to Kirkland^ the credit for 
procedures and treatment that had been made public 
a year previously by Charles White. But then, 
Kirkland was apparently a Scot,^ and the perfervour 
v^th which Scottish obstetricians are treated throughout 
Sinclair's work save where, as in Gordon's case, they 
anticipated Semmelweis, and the way in which, in 
comparison, English work and English obstetricians are 
belittled can only in the circumstances be ascribed 
to an intellect that had come to lack poise 
through advancing age and the inevitable physical 
changes associated therewith. When one remembers 
Sir William's concise contributions to his Subject in the 
earlier days, and his notable influence in the organisation 
and development of the school, the book under 
discussion is pitiful : it is so extraordinarily one-sided, 
strikingly lacking in grasp and in the orderly presenta- 

1. Kirkland, T., M.D. ^A Treatise on Child-bed Fevers and the 
methods of preventing them.^ London, 1774. 

2. * We may presume that Kirkland was a Scotsman from Glasgow 
or Lanarkshire, attracted to London by the fame of Smellie and the 
two Hunters.' Sinclair, loc. cit : p. 339. As a matter of fact, 
Kirkland (1722-1798) graduated M.D. at St. Andrews in 1769. 



THE 'AETIOLOGIE' 17 

tion of its subject, and defeats its object by its very 
prolixity. In this matter of Kirkland, for example, 
Sir William deals with him before White, but fails to 
notice that Kirkland's book was in fact due to White's 
direct appeal, and, what is more, that it was dedicated 
to him. 

It is a pathetic yet irritating picture that Sinclair 
draws of Semmelweis, of a man who was his own 
worst enemy : with a passion for work and a tender 
heart for his patients, but so imperfectly educated that 
he, an Hungarian living in Vienna, never mastered 
the German tongue. Too proud to acknowledge his 
weakness and obtain help from others, for long years 
he refrained from publishing his results. He was 
content to have distinguished friends like Skoda and 
Hebra write on his behalf ; he was either too loyal or 
too heedless to complain or correct when they, not 
unnaturally, published incomplete statements, yet he 
was fooHshly indignant when others at a distance, 
basing their contributions on these imperfect repre- 
sentations of his views, were unable to accept them as an 
adequate survey of the whole ground. After four years 
he gave a full description of his work and stated his 
conclusions before the Vienna Medical Society, but 
then instead of handing in his paper for publication, he 
left it to the Secretary to publish an epitomised report, 
which, naturally, was both imperfect and inaccurate. 
Surely it is not the fault of the medical world if in 
these circumstances it failed to grasp the full 
significance of Semmelweis's message, and paid scant 



i8 WHAT BOER ACCOMPLISHED 

attention to his magnum opus the ' Aetiologie. ' 
This when at last it appeared (1861) was badly arranged, 
indescribably diffuse and argumentative, with constant 
digressions, written in the style of a scrivener, 
v^th wearisome iteration of phrase that out-Daniels 
Daniel in that chapter upon the Miracle of the Three 
Holy Children and its recurrent ' trumpets, sackbuts 
and shawms.' 

Add to this that on reading the book it is clear that, 
despite the remarkable reduction in the mortality 
from puerperal fever accomplished by Semmelweis in 
Lying-in wards of the Allegemeines Krankenhaus in 
Vienna, he was never able to reduce the death-rate there 
to that of his predecessor Boer. Boer it was who, on 
his appointment as Professor of Midwifery in 1789, 
introduced the methods he had learned in England. 
In the thirty years during which he held the post 
65,000 patients came under him in the Lying-in 
Hospital, with an average annual mortality of 1.3 per 
cent. That for his last year was 0.8 per cent. Under 
Klein, Boer's successor, the mortality rose the first 
year to 7.8 per cent, and usually remained high, 
sometimes being appalling, rising in some months to 
20.84 and 29.33 per cent.^ In one division of the 
hospital the mortality from puerperal fever during the 
years 1 841 -1846 inclusive varied between 6.8 and 15.8 
per cent. ; the average for 20,042 cases during the six 
years was just under 10 per 100. During Semmelweis's 
regime in the year 1848 the death-rate among 3,556 

I. Sinclair, Sir W. loc. cit : pp. 51, 55, and 33. 



THE ENGLISH METHODS 19 

patients fell, in this same division, to 1.27 per cent. 
In his first year at Pesth, it is true that Semmelweis's 
mortality was only 2 out of 514 patients, or just under 
0.4 per cent., but in the next two years it rose to 
2.8 and 4.0 per cent. 

Yet Sinclair, while he gives these facts, makes no 
comment upon them and draws no deductions. 
He does not, or will not, see that practically all that 
Semmelweis accomplished was to demonstrate 
absolutely that the earlier, English, methods had been 
on sound lines and that reversion to those methods 
brought about a rapid reduction of mortality (for, 
practically, this was what Semmelweis put into 
operation) ; and that the main cause of the appalling 
incidence of puerperal fever in the Vienna Lying-in 
Hospitals was want of cleanliness and especially the 
practice of allowing students, after they had come 
straight from the post-mortem room, to examine the 
patients without first adequately cleansing their hands.^ 
This, I admit, was a notable achievement, based on 
notable studies, but original only in the sense that 
he took up anew the old problem and utilised nobly the 
abundant material before him for its elucidation. 
He admitted other modes of infection, such as neglect 
to employ clean bed-linen, the presence of open 
suppurating wounds in neighbouring beds and ' self- 

I. Semmelweis regards his Table XVII {Aetiologie, p. 62) as 
affording ' an irrefragable proof of my opinion that puerperal fever 
originates in the carrying over (Uebertragung) of decomposed animal- 
organic matter ; . . . when the Vienna School adopted the anatomical 
basis of instruction the unfavourable" health condition of the Lying-in 
women began.' 



20 WHITE'S TEACHING 

infection,' that is to say, the lochia, remnants of 
decidua and blood coagula which are retained may 
undergo decomposition and when absorption occurs 
produce puerperal fever.^ It has, nevertheless, to be 
admitted that Semmelweis's methods, in his own hands, 
were incapable of preventing all the modes of infection. 
He was, for example, helpless in the group of cases of 
^ self-infection,' and in this respect his teaching was far 
behind that of Charles White. His great achievement 
was in the demonstration of the value of antiseptic 
treatment of the hands of the examiner, and recognition 
of the supreme virtue of chlorine preparations, and 
foremost among these of a solution of bleaching 
powder. But even in this he had been anticipated by 
British obstetricians and was knovsdngly employing 
their methods. 

IV 

White's Teaching 

It is human to imagine that there were no heroes 
before Agamemnon, no antiseptic treatment before 
Lister. But in its prime sense of that which hinders 
sepsis, or putrefaction, the word ' antisepsis ' was in 
use in 1751,^ and was employed by James Lind,^ the 

1. Sinclair, Sir W. loc. cit : p. 205. 

2. GentlemarCs Magazine quoted in the New Oxford Dictionary. 

3. Lind, J. An essay on the most effectual means of preserving the 
Health of Seamen in the Royal Navy (antiseptic sprinklings, aromatic 
fumes), pp. 60 and 86. London, 1757. 



PUTRIDITY AND PUERPERAL FEVER 21 

pioneer in naval hygiene, in 1757 ; by Charles White^ 
and T. Henry^ in 1773 ; by Joseph Priestley^ and 
Thomas Kirkland^ in 1774. White, in particular, 
draws attention to the part played by retained lochia 
in producing puerperal sepsis. Foul air and 
surroundings, filthy bedding, as well as the retention 
of the lochia and the excreta, are in his opinion the 
primary causes of the appearance of puerperal fever. 
' The danger does not arise from the smallness of the 
quantity of the discharge, but from its stagnation 
whereby it becomes putrid and in this state is absorbed 
into the circulation.'^ 

Kirkland ( 1 774) had similar views, holding that inflam- 
mation of the uterus and a consequent absorption of 

1. White, C. ' The Management of Pregnant and Lying-in 
Women.' 1773, pp. 173, 174. 

2. Henry, Thomas. * On the Comparative Antiseptic Powers of 
Vegetable Infusions prepared with Lime,' in his Experiments and 
Observations. London, 1773. 

3. Priestley, J. Observations on Air. p. 228. 

4. Kirkland, T. ' A Treatise on Childbed Fevers and the methods 
of preventing them.' London, 1774. 

5. Just as Semmelweis ascribed puerperal fever primarily to 
putrefaction, so White regarded it as a putrid fever : — 

' When a woman is in labour, she is often attended by a number of 
friends in a small room, with a large fire, which, together with her own 
pains, throw her into profuse sweats ; by the heat of the chamber, 
and the breath of so many people, the whole air is rendered foul and 
unfit for respiration ; this is the case in all confined places, hospitals, 
jails, and small houses inhabited by many families, where putrid fevers 
are apt to be generated the more so where there is the greatest want 
of free air. Putrid fevers thus generated are infectious, witness the 
black assize, as it is usually called.' (White, loc. cit. 1st edition, p. 4). 

Other quotations might be given showing that he held that foul air 
and surroundings, and more particularly the retention of the lochia 
and excreta, were the primary cause of the appearance of the fever 
which, once developed, could be conveyed to other lying-in women. 



22 ANTISEPTIC TREATMENT AND DRAINAGE 

putrid matter from this organ will bring on puerperal 
fever. Regarding one of his cases he states : ' I should 
indeed have been glad if the uterus could have been 
washed out with antiseptic injections, but this, from a 
variety of obstacles, is seldom practised.' In the second 
edition of his book (1777) White advised that whenever 
the lochia became offensive, warm water should be 
frequently injected into the uterus hy means of 
a syringe ' which had a thick siphon and was a little 
curved.'^ In the third edition (1784) occurs the passage 
concluding the chapter upon treatment to which, in 
his address, Lloyd Roberts drew particular attention : 
' I must not omit to mention in this place the good 
effects I have experienced from emollient or antiseptic 
injections into the uterus, by means of a large ivory 
syringe or an elastic vegetable bottle. In those cases 
where the lochia have become acrid or putrid and, by 
being absorbed into the circulation, have served 
as a constant fomes for the disease, I have by this 
means known the fever much assuaged, and in many 
cases wholly extinguished ; for though, as I have before 
observed, the quantity of the lochia is not to be much 
regarded, the quality of this discharge is a matter of 
infinite importance.' 

He held so strong a belief in the damage of retained 
discharges that just as surgeons the world over to-day 
practice free drainage and place the patient in such a 
posture that this free drainage is favoured, so he 

I. See * Appendix* to the Second Edition here reproduced, p. 141 
(note). 



PUERPERAL FEVER AND WOUND FEVER 23 

recommended that so soon as possible after delivery the 
patient be made to sit up or be placed in a reclining 
position to the end that the discharges from the 
womb gain a free exit and are not retained so as to 
undergo putrefactive changes ; and what is more, that 
she should get up and about in the second or third day 
at the latest. [Consult pp. 6^^ 108, iii et. seq.] 

This teaching of White's has of recent years been 
rediscussed, and is again coming to the fore in the 
practice of some obstetricians. White, in short, 
demonstrated seventy years before Semmelweis how to 
guard against and prevent that self-infection which 
the latter regarded as forming the residuum of cases of 
puerperal fever, which he was powerless to prevent. 
Further, Charles White was so successful in his practice 
that he was able to say that in his extensive experience 
of more than twenty years, while cases of puerperal 
fever had occurred through non-observance of the rules 
he had laid down, he had never lost a single patient of 
this disease.^ 

As to the extent of his experience it must be remem- 
bered that for many years after commencing practice 
he had the care of all the parish poor, not only of 
Manchester, but of a large district around it, herein 
succeeding his father. Dr. Thomas White (1696- 1776), 
who had particularly interested himself in midwifery.^ 

1. Compare also the testimony of White's pupil, Cope of Leek. 
'Appendix' to the Second Edition, p. 120. 

2. At a time when ' men-midwives ' were few and far between, 
Thomas White was an active obstetrician. He performed the first 
Caesarean section in the North of England, and Charles White freely 
attributes his methods and his success to his father's example. 



24 WHITE AND SIMPSON 

Nay more, as my old friend, the late Dr. Cullingworth 
has pointed out, he had enlightened views as to the 
nature of the disease. ' Every surgeon,' writes White, 
* conversant with his business knows that a rapid pulse 
(i.e. fever) never fails to attend absorption of matter 
from abscesses or ulcers, whatever be the other con- 
comitant symptoms. ... If to these considerations 
we add that, as the puerperal fever is more fatal in 
large cities and crowded hospitals than in places where 
the air is more open and pure, so is the fever occasioned 
by the absorption of matter . . . (and) that as the 
puerperal fever does not appear till after delivery, so 
neither does absorption of matter from an abscess till 
it be opened and the air have access, we may, I think, 
conclude that the absorption of matter is the immediate 
cause of the puerperal fever as well as of that consequent 
upon abscesses and ulcers.'^ In other words, White 
recognised, long before Sir James Simpson wrote his 
classical essay on the subject (1850)^ the close analogy 
between the fever that followed surgical operations 
(and the ulceration of wounds), and the fever to which 
lying-in women are liable.^ 

But Sinclair took no note of all this. He gives three 
and a half pages to Kirkland, half a page to White, 
referring to ' one point alone ' as worth recalling in 

1. Vide 'Appendix/ p. 105. 

2. Simpson, Sir J. ' Some notes upon the Analogy between Surgical 
Fever and Puerperal Fever.^ Monthly Journal of Med. Science. 
Edinburgh, 1850. 

3. See C. J. Cullingworth. ' Charles White, F.R.S.' London, 
1904 ; p. 28. 



WHITE ON ABSOLUTE CLEANLINESS 25 

White's prophylaxis, and that with disapproval, namely, 
early sitting up. He cannot have studied the original 
or he would have recognised that White laid equal 
importance with Semmelweis upon the decomposition 
and putrefaction of the uterine contents, and upon the 
relationship between puerperal fever and ' pyaemia.' 
Seventy years before Semmelweis, the English school of 
obstetricians were showing how to combat puerperal 
fever with a success at least equal to that of Semmelweis ; 
and Charles White of Manchester, developing the 
practice of his father, Thomas White, was the leader in 
the revolution. 

White's system was that of absolute cleanliness 
in all the surroundings of the patient. ' Her 
lying-in chamber to be in every respect as sweet, 
as clean, and as free from any disagreeable smell as any 
other part of the house. . . . The room is to be 
brushed every day, and the carpets taken out to 
be cleaned and aired. . . . The patient is to be 
often supplied with clean linen, and clean well- 
aired sheets are to be laid upon the bed. . . . The 
windows are to be opened ... no board or other 
contrivance to block up the chimney, the curtains 
not to be closely drawn. ... In hospitals, if 
separate apartments cannot be allowed to every patient, 
at least as soon as the fever has seized one she ought 
immediately to be moved into another room, not only 
for her immediate safety, but that of the other 
patients ; or it would be still better if every woman 
were delivered in a separate ward and was to remain 



26 ROBERT COLLINS OF THE ROTUNDA 

there a week or ten days, until all danger of this fever 
is over.'^ The diet is to be simple, the bowels kept 
open, and alcohol is to be eschewed. Whenever a 
patient has recovered from this fever and is removed to 
another room, the bedding and curtains should be 
washed, the floor and woodwork should be cleansed with 
vinegar, and it would add to the salubrity of the 
apartment if it were stoved with brimstone.'^ 



The Application of White's Teaching 

We see the influence of White's teaching in that first 
important report^ from the Rotunda Hospital, Dublin, 
that of Robert Collins, for the period of his mastership, 
1826 to 1833, long years before Semmelweis. It is 
only during this century that the bacteriologists have 
by experiment determined that nascent chlorine is the 
most rapid and effective of all disinfectants where 
organic matter is present, and actually during the 
War that we have had developed the methods of wound 
treatment by nascent chlorine of Lorraine Smith and 
Dakin. With our existing knowledge and satisfaction 
over our accomplishments, it is hard to believe that 
what I am going to quote was written eighty-five years 

1. Charles White, loc. cit. first edition, pp. 129, 130 and 169. 

2. Ibid. p. 173. 

3. Collins, R. * A practical treatise on Midwifery^ containing the 
result of 16,654 Births occurring in the Dublin Lying-in Hospital during 
a period of seven years, commencing November, 1826. London, 1835. 



CHLORIDE OF LIME 27 

ago : it sounds so modern. Collins entered upon his 
mastership at the end of 1826, after puerperal fever 
had prevailed to an alarming extent. In 1827 the 
disease was slight ; in 1828 the fever was much more 
severe, proving fatal to twenty-one women, and it 
continued to increase in violence in January and 
February and the beginning of March, 1829. In 
February he had all the wards in rotation filled with 
chlorine gas in a very condensed form for the space of 
forty-eight hours, during which time the windows, 
doors, and fire-places were closed so as to prevent its 
escape as much as possible. The floors and all the 
woodwork were next covered with the chloride of lime, 
mixed with water to the consistence of cream, for 
forty-eight hours. The woodwork was then painted, 
and the walls and ceilings washed with fresh lime. 
The blankets and similar articles were in most instances 
scoured, and all stoved to a temperature of between 
120° and 130°.^ 

' From the time this was completed until the termina- 
tion of my Mastership in November, 1833, we did not 
lose one patient by this disease. As the wards of the 
Hospital are occupied by the patients in rotation, as 
soon as each in succession was vacated I continued the 
use of the chloride of lime, confining its application to 
the floors. In this way each ward was washed every 
ten or twelve days, the solution being left undisturbed 

I. It is interesting to compare with this the methods of that earlier 
pioneer in obstetrics, Professor Thomas Young of Edinburgh in 1774, 
the year after the pubHcation of White's book, given in the * Appendix ' 
here reproduced, pp. 117 et. seq. 



28 VENTILATION 

for twenty-four hours, during which time the blankets, 
quilts, linen, etc., were suspended, so as to be exposed 
completely to the chlorine gas, which is copiously 
disengaged from the preparation mentioned.'^ (The italics 
are mine.) 

He then proceeds to describe his care in regard to 
the ventilation of the wards, exactly along the lines of 
Charles White's recommendations. With him he 
enjoined that the ventilation be put beyond inter- 
ruption by the nurses or patients, by the provision of 
ventilation-holes in the ceilings, through the upper 
sashes of the windows and ov^r the doors. 

White was an ardent believer in fresh air. He 
recommended the building of special lying-in wards 
* so contrived that the air might be kept in constant 
circulation, in such a way that there would be no 
danger of the creation or communication of this 
disorder. 

' The rooms must be lofty, open galleries (i.e., 
passages) with unglazed windows should run through 
the whole buildings. The wards should all be upon the 
centre floors, and they should have no doors except into 
the galleries, and those doors should be opposite to the 
windows in the wards, that there may be a thorough 
ventilation of air when the windows are opened. 
In the upper part of the doors should be several holes 
to let out the foul air . . . 

' An entire apartment should be allotted to every 
patient, or else if large wards were constructed the 
windows should be placed very high, with the upper- 



WHITE ON VENTILATION 29 

most sashes made to let down. Large apertures should 
be made as high as possible in the partition wall which 
divides the wards from the gallery, after the manner 
of the Leicester Infirmary ; and in the upper part of 
some of the windows the furthest from the fire should 
be fixed a few leaden lattices to admit fresh air, or, 
what is still better, circular, or as they are called by some, 
^Eolian ventilators. I do not suppose that the superior 
advantages of these ventilators over a leaden lattice 
consists in admitting more fresh, or extracting more 
foul air ; but by their circulatory motion they prevent 
the air from rushing directly upon the persons in the 
room, and thereby giving them cold. They should be 
kept open night and day, that a constant circulation of 
air be maintained ; for it will not be sufficient if a door 
or even a window is opened a little in the middle of the 
day only, of which whoever will take the trouble to go 
into a ward of a hospital early in a morning vnll 
thoroughly be convinced, the air having been rendered 
so foul and disagreeable by a number of people breathing 
in it a whole night as to make the atmosphere very 
unwholesome, not only to lying-in women, but to any 
other person. 

' Several air pipes made of wood of about six inches 
diameter, fixed in every ward and passing through the 
ceiling and the roof, have been found very useful in the 
Manchester Infirmary. I have been in a great number 
of hospitals, but I do not know any so free from foul air 
as that Infirmary, which may, I think, be easily 
accounted for . . . In the galleries, and in many of 



30 COLLINS'S RESULTS 

the wards, lead lattices are fixed in the windows. Holes 
are cut in the upper parts of the doors, and the doors 
are generally open in the day-time. In the largest 
wards are openings in the walls likewise to admit 
fresh air . . . 

' Besides air pipes carried through the roof, others 
may be let into the chimney of the ward above as has 
been practised at St. George's Hospital.'^ 

At the Rotunda, Collins carefully copied most of 
White's recommendations, and he states : — ' Of 10,785 
patients delivered in the Hospital subsequent to this 
period only 58 died, which is nearly in the proportion 
of one in every one hundred and eighty six, the lowest 
mortality perhaps on record.' That is 0.53 per cent, 
mortahty, and this not from puerperal fever. To 
repeat, there was not one death from that disease. 
It was from all other causes. I doubt if even to-day, 
with our fuU development of asepsis, any French, 
German or Austrian Maternity Hospital can show better 
figures. And this was thirty years before Pasteur 
founded the science of bacteriology and established the 
microbic nature of infection, thirty-five years before 
Lister introduced his antiseptic methods into surgery, 
and fifteen and more years before Semmelweis. More- 
over, Semmelweis never obtained such results. I admit 
that granting the time and the place Semmelweis's 
results were notable and most striking ; but they were 
not original. I admit also, and freely, that by the 
early forties other influences were at work in Great 
I. Charles White, loc. cit. 1st edition, pp. 162-167. 



THE * EPIDEMIC DOCTRINE 31 

Britain : that Charles White's great work had become 
old-fashioned and forgotten and his methods had 
lapsed, even in Manchester itself, so that puerperal 
fever again raised its head and the mortality at St. 
Mary's Hospital became a matter of the gravest concern. 
This fact, however, must not be laid to White's account, 
but to the diffusion of foreign, and particularly French 
teaching as to the nature of puerperal fever and its 
epidemic character. It was the later appearance of 
that same wave of erroneous ' epidemic ' doctrine 
obtaining on the Continent which, in 1826, on the 
ground that his procedure was old-fashioned and 
based on ' contagionism,' had at Vienna forced the 
resignation of Professor Boer, and had led to the 
disastrous introduction of Professor Klein and his 
* anatomical ' teaching into the AUegemeines Kran- 
kenhaus. 

VI 

The Teaching of Semmelweis 

/ Let us once for all analyse and present Semmelweis's 
teaching. It is this, as stated in the ' Aetiologie,' the 
ultimate full statement of his theory and practice, 
published in i860. I give it as translated by Sinclair.^ 
* Puerperal fever is not a contagious disease, but 
puerperal fever is conveyable from a sick to a sound 
puerpera by means of a decomposed animal organic 
material. 

I. Sinclair, loc. cit., pp. 202, et seq. 






32 THE TEACHING OF SEMMELWEIS 

I ' I maintain that puerperal fever, without the 
exception of a single case, is a resorptive fever produced 
hy the resorption of a decomposed animal organic 
material . . . (This) is, in the overwhelming majority 
of cases, brought to the individual from without ; these 
are the cases which represent child-bed fever epidemics ; 
these are the cases which can be prevented. 

' In rare cases the decomposed animal matter which 
when absorbed causes child-bed fever is produced 
within the limits of the affected organism. . . . 

* The sources of the decomposed animal organic 
material which conveyed from without, causes puer- 
peral fever are all diseases ... if only the disease in 
its progress produced a decomposed animal organic 
material . . . only the decomposed animal organic 
material as a disease producer has to be taken into 
consideration. . . . What the object actually represents 
is of no importance ; it is the degree of putridity which 
has to be considered. 

' The carrier of the decomposed animal organic 
material is everything that can be rendered unclean 
by such material and then come into contact with the 
genitals of the patient. . . . 

* Puerperal fever is therefore not a species of disease 
(i.e., a specific disease) (but) a variety of Pyaemia. . . . 
I understand by Pyaemia a blood poisoning produced 
by a decomposed animal organic matter . . . This 
disease can be produced in a normal healthy puerpera 
by a disease which is not puerperal fever. ... 



CONTAGION AND ' UEBERTRAGUNG ' 33 

' There are no epidemic influences capable of 
producing puerperal fever . . . epidemic, that is to 
say atmospheric, cosmic, telluric influences ... If (it) 
were produced by (such epidemic influences) it could 
not be prevented . . . . (It is not bound up with any 
season in particular . . . p. 217.) The medical pro- 
fession in England regard puerperal fever as contagious. 
.... That puerperal fever is not contagious is my 
belief. 

' But puerperal fever is conveyable (uebertragbar) 
. . . but only from those infected women who 
produce decomposed material. After death (it) is 
conveyable from every cadaver of a puerpera to a 
healthy individual when the cadaver has reached the 
necessary degree of decomposition (p. 224). 

' The task of prophylaxis of puerperal fever must 
consist in preventing the access of decomposed 
material from without, the arrest of the development of 
such material within the organism, and the removal as 
quickly as possible from the organism of such a material 
so as to prevent its resorption. 

' All pathological anatomy and even surgical work 
in the curriculum should be finished before the practice 
of midwifery has begun. 

' The conveyer of the decomposed matter may also 
be the air. Hence free ventilation is necessary (so as to 
prevent the development of a puerperal miasma). 
Isolation rooms should be provided. 

* As regards " self-infection," if decomposed material 
has actually been produced in the individual it must be 



34 GORDON OF ABERDEEN 

at once got rid of by cleanliness and injections so as to 
prevent resorption as far as possible.' 

Leaving aside for the time being Semmelweis's 
doctrine of decomposed animal organic material, the 
only serious difference between the English school, as 
represented by the obstetricians at the end of the 
.eighteenth century, and Semmelweis, in the middle of 
the nineteenth, is that the one believed in contagion, 
the other in Uebertragung. Instead of showing, 
as he ought to have done, that with our present 
knowledge of the nature of puerperal fever this is a 
distinction without a difference, Sinclair solemnly and 
unbelievably emphasises that the distinction is all- 
important. 

So far as I can discover, from 1774 ^^ ^^4^ ^^ 
British writer of the first rate claimed that puerperal 
fever was a specific disease. While some pointed out 
the close relationship of this condition with erysipelas, 
others with scarlet fever, and others again — like 
Charles White — with jail fever, or — like Collins and the 
earlier workers in Dublin — ^with typhus, not one of them 
claimed that all cases were erysipelas or scarlet fever 
or typhus. Nor was Semmelweis original in his 
demonstration that students and those attending the 
lying-in woman might convey the disease to her. 
Gordon of Aberdeen^ in 1795 had recognised that those 
in contact with, or in attendance upon, cases of 
puerperal fever might convey the condition to others 
in the puerperal state, and Oliver Wendell Holmes, 
I Gordon : *0n the Epidemic Puerperal Fever in Aberdeen,' 1795. 



\ 



'MALO ERRARE CUM GALENO' 35 

as is well known, had, prior to Semmelweis, emphasised 
this danger in 1843. What is that but Uebertragung ? 
As I have pointed out, the doctrine of self-infection 
admitted by Semmelweis goes back to Charles White. 
We in the medical profession are the slaves of words 
of indefinite meaning, words which cloak our ignorance 
and are a curse to clear thinking — words such as 
' contagion,' ' septicaemia,' and * pyaemia.' To some 
of us at certain periods ' contagion ' has meant the 
direct conveyance of infection by immediate contact 
between the infected individual and one hitherto not 
infected. To others at the same time or at other 
periods it has meant infection transmitted by any 
means and through any intermediary ; to others again 
' contagion ' implies, and Sinclair employs the word in 
this sense, infection, however conveyed, by a sharply- 
defined species of disease. Semmelweis could not use 
the term ' contagion ' simply because he did not believe 
that puerperal fever was an infection ; for him it was an 
intoxication set up by decomposed animal matter. 
We may admit that it was not his fault that he was 
wrong, and that had he lived thirty years later he would 
have been eager to embrace the knowledge of the 
microbic causation of the condition. The fact remains, 
however, that the contagionists, so called, were nearer 
to the truth than he : they, at least, saw that they 
dealt with an infectious condition or conditions. 
Yet Sinclair in 1909 preferred to err with Semmelweis 
rather than to embrace the truth with his fellow- 
obstetricians in Great Britain. 



36 THE MODERN TEACHING 

For some reason or another the late Professor 
Sinclair either had little appreciation of bacteriology 
or found it to his interests to act as advocate for 
Semmelweis and to carp at modern investigation. 
So little apparent acquaintance had he with scientific 
progress that, in 1909, he asserts that the discussion 
on the etiology and nature of Puerperal Infections at 
the International Congress at Paris in 1900 presented 
all the ascertained knowledge of the bacteriology of 
puerperal sepsis up to a period nine years later than 
the date of the Congress, stating that * nothing of 
essential importance had been added to this department 
of bacteriological knowledge ' (p. 364), and making the 
statement elsewhere that ' the very latest question 
raised in the confused tug-of-war ' is with regard to the 
* haemolytic influence of the streptococcus,' by which 
I presume he meant ' the special virulence of haemolytic 
members of the streptococcus group.' 

VII 

The Modern Teaching 

Yet, as the late Dr. Arnold Lea,^ a member of 
Sir William's own staff, showed in his important work 
written a few months later, the studies upon strep- 
tococci and upon their relationship to puerperal fever 

I. Lea, Arnold W. W., M.D., B.Sc, F.R.C.S., Lecturer in 
Gynaecology and Obstetrics, Univ. of Manchester ; Assistant Surgeon 
to St. Mary's Hospital. * Puerperal Infection.'* Oxford Medical 
Publications, 1910. 



PATHOGENIC SAPROPHYTES 37 

have solved the problem of the etiology of the disease. 
It will be useful here to sum up the present day- 
bacteriological conclusions regarding that etiology : 

1. Putrefaction is essentially caused by bacteria, 
so that the ' Uebertragung ' of decomposed animal 
organic material meant always the conveyance of 
bacteria. 

2. Not all the organisms that set up decomposition 
of animal matter are by any means necessarily patho- 
genic. 

3. Not every case of conveyance of cadaveric 
material will therefore cause infection of the puerperal 
uterus or other wounded surface. 

4. The organisms which most frequently cause ter- 
minal infections, which therefore are most frequently 
present post mortem, are members of the streptococcus 
group ; these at the same time are the commonest 
saprophytes on the skin and mucous membranes of the 
body. 

5. So long as the skin and mucous membranes are 
intact, for so long may streptococci and other microbes 
of a highly virulent nature persist on the unbroken 
surfaces without setting up disease. 

6. The organisms which in an overwhelming 
majority of cases set up and are found associated with 
puerperal fever are members of the streptococcus group, 
and of these again the overwhelming majority are 
haemolytic strains^ As with wounds in general, other 
organisms may be present and may preponderate or 



38 THE MODERN TEACHING 

be in practically pure culture in the blood and tissues, 
to the exclusion of streptococci, notably, staphylococci, 
B, coli, strains of pneumococcus, and B. pyocyaneus. 

7. Streptococci, both haemolytic and non- 
haemolytic, and the other microbes above mentioned, 
may be present in the vagina of the pregnant woman. 
These organisms explain ' self-infection.' That every 
puerperal woman does not suffer from 'wound fever ' is 
probably due to the bactericidal action of the 
effused blood and to the strongly acid and inhibitive, 
if not actually bactericidal, properties of the vaginal 
secretion. 

8. Stagnation of the lochia without free drainage is 
known to favour bacterial multiplication and so 
infection of the placental site. Hence the sound 
wisdom of Charles White's principle of womb-drainage. 
The argument that early sitting up favours uterine 
thrombosis is not valid. Such thrombi are of bacterial 
causation, and proper drainage, by preventing infection, 
prevents thrombosis. 

9. Not only do streptococci vary greatly in viru- 
lence, but as Marmorek and others have shown, their 
virulence and haemolytic activity may be increased 
at a rapid rate by passage through animals in series ; 
that is to say, during the sojourn in the body of the 
animal there may be definite increase in virulence. 
Further, growth in confined spaces under favourable 
conditions favours increase in virulence. 

10. No bacteriologist of standing for the last 
fifteen years has seriously supported the view that there 



ASEPSIS AND WOMB-DRAINAGE 39 

is a distinct species of streptococcus, S. erysipelatos. 
In other words, it is accepted that the streptococcus 
which sets up erysipelas in one individual may induce 
peritonitis and other forms of infection in other 
individuals. There may well, therefore, be a correlation- 
ship between frequency of cases of erysipelas in a district 
and frequency of cases of puerperal fever. 

1 1 . Similarly the scarlatinal sore throat — as also the 
diphtherial — is characterised by most abundant local 
growth of streptococci, usually haemolytic in character. 
Several observers have thus held that a streptococcus 
is the cause of scarlet fever, just as prior to the discovery 
of B. diphtheria the same organism was held to be the 
cause of diphtheria. This local growth of strep- 
tococci obtains in other zymotic diseases in which the 
throat is affected. Wherefore we can understand the 
correlationship that has been suggested between these 
diseases and puerperal fever. 

We admit, therefore, that what holds for other 
streptococcal diseases holds true for the origin of 
puerperal fever ; it may originate (a) from a previous 
case of puerperal fever either directly or through the 
intermediation of a third person ; or (b) from a previous 
case of suppurative or other disease, not puerperal fever, 
by like means of conveyance ; or (c) it may be of 
autogenous origin, due to saprophytic organisms which 
possess or acquire exalted virulence and gain admission 
to the unprotected placental site. Streptococci, 
which are the main microbes involved, are so wide- 
spread and are so constantly present upon the human 



40 DISINFECTION OF HANDS 

skin and in the alimentary canal, that in many cases 
it is not possible to state which was the mode of origin.^ 
This, however, stands out clearly, that by following 
the methods of Charles White — by methods of 
scrupulous cleanliness of the patient and her surround- 
ings and of womb drainage — the incidence of puerperal 
fever can be reduced to an almost negligible minimum. 

The one matter to which White does not refer is the 
personal cleanliness of the accoucheur and the midwife. 
So precise is he in his details regarding the cleanliness 
of the lying-in woman, her body and bed-linen, of the 
lying-in room and the wards, that it is difficult to 
imagine that he took no care of these matters. It is 
obvious, from Semmelweis's admission,^ that dis- 
infection of the hands was a well-established British 
procedure prior to his time. 

Now much, if not all, of this knowledge was at the 
disposal of Sir William Sinclair twelve years ago, 
and I cannot but feel that in his desire, however 
kindly, to exalt Semmelweis he unduly and unpardon- 
ably neglected it, to the injury of the great work 

1. For the 'last word' see Eden, The Lancet, Nov. ii, 1922, 
p. lOOI. 

2. The admission is not a little to the point (Sinclair, loc. cit., 
p. 218) :— 

* English practitioners, starting with the conviction that puerperal 
fever is contagious, do not visit a healthy pregnant, parturient or 
puerperal vi^oman when they have paid a visit to an infected pregnant, 
parturient or puerperal patient, without previously disinfecting their 
hands with chlorine disinfectant (the italics are mine) and without 
changing their clothes ; and when the number of puerperal cases 
increases in their practice, they go away from home or completely 
abandon midwifery practice for a time. The English practitioner, 
if he must undertake the post-mortem examination of a patient who 



CHAUVINISM AND STRANGE PROPHETS 41 

accomplished hy British obstetricians at the end of the 
eighteenth and beginning of the nineteenth centuries. 
They it was, and not Semmelweis, who first gained 
control over puerperal fever. They it was who 
introduced free ventilation and as absolute a cleanliness 
as was possible into the lying-in ward and lying-in 
room, who laid stress upon disinfection, who realised 
the value of antisepsis long years before Lister, who 
recognised the worth of chlorine and chloride of lime, 
who introduced the disinfection of the hands and 
drainage of the puerperal wound, who would have no 
truck with the epidemic — that is, the atmospheric, 
cosmic, or telluric theory — but held to the contagious, 
that is to say infective, theory of the origin of the 
disease ; and, holding that, saw the condition was 
preventible and so must be prevented. 

To the seeker after truth it is debatable which is 
the more repugnant: — Chauvinism, with its exaltation 
of the local and national and wilful closing of the eyes 
to the virtues of anything that comes from without, 
or its converse, the running after strange prophets 

has died from puerperal fever, never visits a normal parturient or 
puerperal woman without first pushing the same precautions to the 
fullest extent. 

' In every case in which the infected puerpera produces a 
decomposed material, the English practitioners do something which is 
superfluous but not harmful; they destroy the decomposed material 
in the belief that they are destroying a contagion which would cause 
puerperal fever if carried to a healthy parturient or puerperal woman.' 

And the English practitioners were right and Semmelweis was 
wrong. But Sinclair never admits this. If practice has been altered 
it has been because now we know more concerning hand disinfection 
and its difficulties, and the value of rubber gloves, and certainly not 
as a consequence of Semmelweis's teaching. 



42 THE MANCHESTER SCHOOL x 

and refusal to give honour to the prophets of one's 
own country. It would be difficult to adduce a more 
flagrant example of the latter evil than this afforded 
by Sinclair's volume. Semmelweis deserves to be 
held in grateful remembrance and to be given a place 
in the temple of fame, not for his enunciation of a new 
and true theory — for his theory was quite erroneous ; 
nor again as the originator of sound practice in the 
prevention of puerperal fever — for in not one single 
point was his practice original ; but for his demonstra- 
tion, as timely as it was heroic, of the wrong, not-to- 
say deadly nature of the treatment in vogue prior to 
his re-introduction of the rational methods of the end 
of the eighteenth century. 

The real pioneers in the reduction of puerperal fever 
were the British obstetricians of the latter half of the 
eighteenth century in London, Manchester, Edinburgh, 
and Dublin. Men like Denman, Kirkland, the Whites, 
Young, Ould and Clarke ; and among these assuredly 
Charles White, the founder of the Royal Infirmary and 
of what is now St. Mary's Hospital, takes the first place. 
I can only repeat to-day what the learned Dr. Thomas 
Henry, F.R.S. ('Magnesia Henry') said concerning 
White's magnum opus, in his obituary memoir read to 
the Manchester Literary and Philosophical Society in 
April, 1813 : ' Perhaps, indeed, few medical books have 
been productive of more important reform in practice, 
or of more comfort and safety to the subjects for whose 
benefit it was intended. Nature was restored to the 
free exercise of her operations, and officious ignorance 



THE MANCHESTER SCHOOL 43 

was prevented from converting into fatal disease what 
was benevolently and wisely designed to be a process 
scarcely ever attended with danger.'^ 



VIII 

The Manchester School and its Future 

And from White onward there has been in Manchester 
an able succession of great obstetricians : Hull 
( 1 761 -1 843) who along with White established 
Phlegmatia (or Phlegmasia) alba dolens as a definite 
entity, and laid down clearly the conditions under 
which Caesarean section should be undertaken ; 
Wood (1785- 1 8 30), who was the first to advise that in 
placenta praevia the entire detachment of the placenta 
from the os and cervix uteri should be practised ; 
Thomas Radford (179 3-1881), one of the first in this 
country to propose ovariotomy and a strong supporter 
of Charles Clay (i 801 -1893) who may fairly be regarded 
as the father of ovariotomy in Europe (Clay's first case 
occurred in 1839, and in 1865 he was able to report 
III cases of the operation, ']'] of which were successful) ; 
James Thorburn (1834- 1865), first Professor of 
Obstetrics and Gynaecology at Owens College, author 
of a practical treatise on the Diseases of Women — a 
great teacher ; Charles J. CulHngworth (1841-1908), 
with his notable studies upon ectopic gestation and 

I. Trans. Lit. and Phil. Soc, Manchester ; Series 2, Vol. e. 18 19, 
p. 44. 



I 



44 POST-GRADUATE TEACHING 

pelvic peritonitis, who succeeded him and, following 
CuUingworth, Sir William Japp Sinclair. 

It is a noteworthy list, of which Manchester may 
well be proud, nor has the succession ceased. To-day, 
under Donald and Fothergill, as all who have followed 
this last year's medical journals cannot but realise, 
the School is as vigorous as ever. 

One last word. It is for this generation to make the 
School not local but imperial in scope, and like Dublin 
with its Rotunda to attract students from all parts of 
the Empire. 

Unlike most other Medical Schools known to 
me in Great Britain and America, Manchester 
has developed a most successful post-graduate course 
of the old type — a course of lectures and demonstrations 
upon the newer developments in medicine and surgery. 
It is the centre of perhaps the most densely- 
populated area of the civilised world, and there is a 
sufficient number of practitioners in the immediate 
neighbourhood who find it possible to attend those 
courses without grave disturbance to their practice. 
And this is all to the good. But let me point out 
that this is not post-graduate work of the higher 
type. At most these are ' refresher ' courses. They 
are not calculated for the full education of the specialist 
in his specialty. They do not — they ought not to — 
attract men from a distance to Manchester for advanced 
work of the first quality. However great the utility 
of the present courses, they are not such, either in 
length, or ground covered, or practical training, as to 



THE GORDIAN KNOT 45 

entitle a man to consider them as affording a qualifica- 
tion for special practice. 

Nevertheless, there is to-day a distinct demand for 
this more advanced and expert post-graduate v^ork, 
for work of the type that in the past was provided by 
Vienna and Berlin. For myself, indeed, I look forward 
to the time when we shall cut the Gordian Knot of the 
problem of medical education by shortening and 
simpHfying, and not by lengthening and further 
compHcating, the course leading to the first qualifying 
examination ; when we shall grant the M.B. to the man 
who has been given instruction in the general principles 
and ordinary practice of Medicine, Surgery, and 
Obstetrics ; shall demand then that every graduate 
who intends to take up general practice shall spend 
a year in hospital prior to being given his licence to 
practice, while those ambitious to take up special 
work in the medical sciences (anatomy, physiology, 
pathology, etc.) or in medicine, surgery, gynaecology 
and the specialties, shall be required to give not one 
but two years to advanced work in the medical school 
and hospital combined, in one or other particular 
direction, leading to a Diploma or, if thought fit, a 
Master or Doctor's Degree. 

This parenthetically. In the meantime it is for those 
medical centres which possess particular schools or 
departments well-equipped, and with a reputation 
and tradition in teaching and research, to make use of 
those particular schools, encouraging those from 
outside and overseas to take advantage of the 



46 A DEGREE IN GYNAECOLOGY 

opportunities they afford. It would be futile for any 
British School of Medicine to invite post-graduate 
students to attend special courses extending over two 
years or so in every branch of medicine and surgery ; 
men will only be attracted by teachers of repute. 
Liverpool, for example, with the established tradition 
of Thomas and Sir Robert Jones, is offering to medical 
graduates of approved Universities an intensive course 
of lectures, laboratory and hospital work, of fifteen 
months in Orthopaedics, beginning in October of one 
year and extending through the Long Vacation to 
December of the next ; a course leading to a second 
degree of Bachelor of Orthopaedic Surgery. With its 
continuing tradition and abundant clinical facilites 
why should not Manchester offer a similar course in 
Obstetrics, or more broadly, in Gynaecology ? The 
other two great branches of our common subject have 
their degrees. 

I suggest that the time is ripe for the development, 
in the school of Charles White, Hall, Clay, Radford, 
Robert on, Thorburn, CuUingworth, Sinclair and Lloyd 
Roberts, of a post-graduate course of such high order 
that the possession of the Manchester degree in 
Gynaecology should in itself stamp the possessor as a 
fully- qualified expert. 



CHARLES WHITE'S WRITINGS 

UPON " 

PUERPERAL FEVER 

REPRODUCED FROM THE FIRST EDITION OF HIS TREATISE UPON 

THE MANAGEMENT OF PREGNANT AND LYING-IN WOMEN 

(LONDON, 1773) 

WITH THE APPENDIX TO THE SECOND EDITION 
(LONDON, 1777). 




CHARLES WHITE, F.R.S. 

Reproduced from the mezzolint e7tgravmg by W. Ward (1809}, 
after the portrait by Joseph Allen. 



A 

TREATISE 

ON THE 

MANAGEMENT of PREGNANT 

AND 

LYING-IN WOMEN, 

AND THE MEANS OF CURING, BUT MORE ESPECIALLY 

OF PREVENTING THE PRINCIPAL DISORDERS 
TO WHICH THEY ARE LIABLE. 

TOGETHER WITH SOME 

NEW DIRECTIONS 

CONCERNING THE 

DELIVERY OF THE CHILD AND PLACENTA 

IN NATURAL BIRTHS. 

lUuftrated with Cases. 
By CHARLES WHITE, F. R. S. 

Member of the Corporation of Surgeons in London, and Surgeon 
to the Manchester Infirmary. 

LONDON: 

Printed for Edward and Charles Dilly, in the Poultry. 

MDCCLXXIII. 



CHAPTER I 

Of the Causes and Symptoms of the Puerperal 
OR Child-bed Fever^ 

Women, during the time of lying-in are subject to this 
fever, which has evident symptoms of putrescency, 
and which if not properly managed has often fatal 
effects. 

That child-bed women should be so [2]^ liable to putrid 
fevers,^ is not to be wondered at, if we consider every 

1. This disorder in the northern parts of this Island is called the 
weed ; and in the southern parts hy some, improperly, the lochial fever. 

2. Editor's Note. These figures in brackets indicate the beginning 
of the pages so numbered in the first edition. 

3. * Puerperse ex male affecti corporis vitio tanquam aurae 
pestilentialis contagio tactae febri putridcPf seu potius maltgnce quam 
nimium obnoxiae reperiuntur ; hujusce vero morbi labem haud omnes 
ex aequo suscipiunt : etenim pauperes rusticae, aliaeque duris laboribus 
assuetae, nee non viragines, & meretrices, quae clandestina agunt puer- 
peria, sine magna difficultate pariunt, & deinceps brevi a lecto excitatae, 
ad solita redeunt opera ; mulieres autem ditiores, tenellae, & pulchrae, 
pleraeque vitam sedentariam degentes, quasi maledicti divini graviori 
modo participes in dolore pariunt, indeque mox a partu difficiles & 
periculosos subeunt casus.' — Willis de Febribus Puerperarum, Febres 
putridse Caput xvi. 

Willis's account would not have been liable to any material objection, 
if he had not excepted the poor in general, for it is now well known 
that they are very liable to this fever both in the hospitals, and in their 
own houses, especially if they are situated in the middle of large 
manufacturing towns and cities ; but there is this to be said in favour 
of the Doctor, that it is above a century since he wrote this Treatise on 
the Puerperal fever, at a time when there was no hospital for lying-in- 
women in the British dominions, our manufacturies were then in their 
infancy, and the diet and mode of living amongst the poor people, 
were totally diiferent from what they are at this time. 



52 CHARLES WHITE 

circumstance, and every inconvenience they lie under, 
owing to bad fashions and customs ; but to trace them 
up to their original source we must look back as far as 
the early months of pregnancy. At this period the 
tightness of the stays, and petticoat bindings, the weight 
of the pockets, and of the petticoats, press the womb 
already enlarged by the foetus [8] and its membranes, so 
strongly against the lower intestines, as to prevent the 
descent and exclusion of the excrements. These being 
retained, the thinner parts are absorbed by the lacteals, 
which cause, or at least greatly increase, that obstinate 
costiveness of which most women complain during the 
whole time of pregnancy, and which is also farther 
increased by a sedentary, inactive life, and improper 
diet. This excrementitious matter being absorbed 
into the circulation undoubtedly occasions a great 
in[4]clination to putridity ; loss of appetite soon 
follows, and the stomach and duodenum being no longer 
distended with aliments, large quantities of bile are 
collected in the gall bladder, the cystic and hepatic 
ducts, and by lodging there soon acquire a putrid, or 
putrescent acrimony. 

When the woman is in labour, she is often attended 
by a number of her friends in a small room, with a large 
fire, which, together with her own pains, throw her into 
profuse sweats ; by the heat^ of the chamber, and the 
breath of so many people, the whole air is rendered [5] 

I. Dr. Thomas Cooper speaking of the lochial fever says, ' this fever 
is most common, and also more fatal in the hotter months.' — Compend. 
of Midwifery, p. 220. Lond. 1766. 



ON PUERPERAL FEVER. Cap. I 53 

foul, and unfit for respiration ;^ this is the case in all con- 
fined places, hospitals, jails, and small houses, inhabited 
by many families, where putrid fevers are apt to be 
generated, and proportionally the most so where there 
is the greatest want of free air. Putrid fevers thus 
generated are infectious, witness the black assize, as it is 
usually called. 

If the woman's pains are not strong enough, her 
friends are generally pouring into her large quantities 
of strong liquors, mixed with warm water, and [6] if 
her pains are very strong, the same kind of remedy 
is made use of to support her. As soon as she is 
delivered, if she is a person in affluent circumstances, 
she is covered up close in bed with additional cloaths, 
the curtains are drawn round the bed, and pinned 
together, every crevice in the windows and door is 
stopped close, not excepting even the key hole, the 
vTindows are guarded not only with shutters and 
curtains, but even with blankets, the more effectually 
to exclude the fresh air, and the good woman is not 
suffered to put her arm, or even her nose out of bed, 

I. It has been found by Dr. Stephen Hales (Statical Essays, Vol. 2, 
p. 324) that a person in health destroys two gallons of air in two minutes 
and a half, so as to render it unfit for respiration. 

Dr. Percival informs me that a correspondent of his, (a gentleman 
distinguished for his knowledge of Natural and Experimental Philosophy) 
has lately discovered * that air which animals have breathed is in all 
respects the same with air in which animals have putrefied. The 
original quantity is equally diminished in both cases ; which is found to 
be owing, in part at least, to the precipitation of the fixed air it 
contained : and they are restored by the same process. One use of the 
lungs therefore must be to carry off a putrid efiluvium, without which 
a living body might perhaps putrefy, as well as a dead one.' 



54 CHARLES WHITE 

for fear of catching cold. She is constantly supplied 
out of the spout of a tea-pot with large quantities of 
warm liquors, to keep up perspiration and sweat, and 
her whole diet consists of them. She is confined to a 
horizontal posture for many days together, whereby 
both the stools and the lochia are prevented from 
having a free exit. This happens not only from the 
posture of the patient, but also from [7] the great relaxa- 
tion brought on by warm liquors and the heat of the bed 
and room, which prevent the over-distended abdominal 
muscles from speedily recovering their tone, whereby 
they are rendered unable to expel the contents of the 
abdomen, which lodging in the intestines many days 
become quite putrid. 

The lochia stagnating in the womb, and in the folds 
of the vagina, soon grow putrid, for it is well known 
that the mildest humours in the human body, if 
suffered to stagnate, become so, as soon as the air has 
access to them. These are in part absorbed by the 
lymphatics in the womb and vagina, and the effluvia 
from them help to make the air in the bed, and in the 
room, more putrid ; this air in every act of inspiration 
is taken into the lungs, and is there again received into 
the circulation : add to this that women are generally of 
a lax, seldom of a rigid fibre, owing in [8] some measure 
to their periodical evacuations, to their sedentary, 
inactive, and domestic way of life, and likewise to their 
muscles being surrounded with a much larger quantity 
of cellular membrane, than those of men ; hence also 
they arrive at their acme sooner than men. 



ON PUERPERAL FEVER. Cap. I 55 

Amongst the poor people who Hve in cellars, and 
upon clay ground floors, the air is still made worse by 
the dampness, and closeness of their houses, and 
the want of clean linen, and cleanhness in general. 
Those who live in garrets are also in no better a 
situation, for the putrid miasmata of several families 
inhabiting the lower part of the house, ascend to them, 
already suffering perhaps from the effluvia of a whole 
family in every single room, the putridity of which is 
farther increased, by the heat of the sun piercing 
through the covering of the house ; nor is it to be 
wondered at that they are still in a worse [9] situation in 
hospitals,^ where a number are crowded, not only in 
one house, but in one ward, where the disease is con- 
veyed from one to another by the putrid miasmata 

I. ' II a regne pendant I'hiver de 1746 une maladie epidemique 
parmi les femmes en couche : M. de Jussieu a le premier observe cette 
maladie ; elle commenfoit par le devoiement, ou par une disposition 
au devoiement, qui continuoit pendant la couche : les eaux qui 
accompagnent ordinairement la naissance de Fenfant, sortoient pendant 
le travail de I'accouchement ; mais apres ce temps, la matrice devenoit 
seche, dure & doloureuse, elle etoit enflee, & les vuidanges n'avoient 
pas leur cours ordinaire. 

Ensuite, ces femmes etoient prises de douleurs dans les entrailles, 
sur-tout dans les parties qu'occupent les ligamens larges de la matrice ; 
le ventre etoit tendu, & tous ces accidens etoient accompagnes d'une 
douleur de tete, & quelquefois de la toux. 

Le troisieme & le quatrieme jour apres Taccouchement, les mammelles 
se fletrissoient, au lieu qu'elles durcissent & se gonflent naturellement 
dans ce temps par le lait qui s'y filtre alors en plus grande quantite : 
enfin ces femmes mouroient entre le cinquieme & le septieme jour de 
I'accouchement. 

Cette maladie n'a attaque que les pauvres femmes, & elle n'a pas 
ete aussi violente, ni aussi commune parmi les pauvres femmes qui ont 
accouche chez elles, que parmi celles qui ont ete accouchees a I'Hotel- 
Dieu ; on a remarque que dans le mois de Fevrier, de vingt de ces 
femmes malades en couche a I'Hotel-Dieu, a peine en echappoit-il 



56 CHARLES WHITE 

lodging in the curtains, [10] bed cloaths, and furniture, 
and by the necessary houses, which are either con- 
tiguous to, or so near the hospital as to occasion a most 
disagreeable smell, and must of course convey that 
infection which cannot be more effectually com- 
municated, than by the excrements, [li] 

The breasts, if drawn at all, are not drawn till 
several days after delivery, when they are so full as to 
be perfectly gorged, and as hard as stones. By this 
means the first milk, which for a very wise purpose is 
thin, purgative, and of a stimulating nature, is thrown 
back into the circulation. 

This description may perhaps seem overcharged for 
a picture of that improved practice which is introduced 
by modern professors of the art ; but upon a close 
examination, I believe it will appear that many of the 

une : cette maladie n'a pas ete si meurtriere dans le reste de I'hiver. 
Mrs. Col de Villars & Fontaine, Medecins de cet Hopital, nous ont 
rapporte qu'a I'ouverture des cadavres de ces femmes, ils avoient vu du 
lait caille & attache a la surface externe des intestins, & qu'il y avoit 
une serosite laiteuse epanchee dans le bas-ventre ; ils ont meme 
trouve aussi de cette serosite dans la poitrine de quelquesunes ; & 
lorsqu'on en coupoit les poumons, ils degorgeoient une lymphe laiteuse 
& pourrie. 

L'estomac, les intestins & la matrice bien examines, paroissoient avoir 
ete enflammes, & il est sorti, suivant la rapport de ces deux medecins, 
des grumeaux de sang, a I'ouverture des canaux de la matrice. 

Dans plusieurs de ces femmes, les ovaires paroissoient avoir ete en 
suppuration.' — Hist, de I'Acad. Royale des Sciences I'an 1746, 4to. 
p. 160. 

* I am well informed that this fever and obstruction occur more 
frequently in the lying-in hospitals, than in private practice. What 
can this arise from but from the different states of air ? This in my 
opinion is the cause, for though very great care is taken in those hospitals, 
yet as the apartments and furniture will imbibe some of the morbid 
eflfluvia, arising from the patients, the air must always be more or less 
tainted.' — Johnson's Midwifery, p. 253. 



ON PUERPERAL FEVER. Cap. I 57 

most important errors do in reality prevail, and this I [12] 
impute in great measure to the large share which nurses 
have in directing the management of lying-in women, 
to whose interference practitioners must in some 
measure submit, though contrary to their better 
judgment. 

Women have frequently many, and sometimes all 
of these difficulties to struggle with, even after the 
most easy deliveries, but if there has been such violence 
used, either by instruments or by the hand, in the 
extraction of the child or the placenta, as to bring on 
an inflammation of the womb, these difficulties will 
still be farther increased. The patient may likewise 
be put upon her labour too soon, by endeavouring to 
dilate the os internum, or be too frequently teazed with 
unsuccessful attempts to deliver her, or after the head 
is born, the body of the child may be delivered too 
suddenly, and too forcibly, without waiting for 
another pain, or [13] giving the shoulders time to accom- 
modate themselves to the different dimensions of the 
pelvis, the bad effect of which I shall explain more at 
large hereafter. 

In a few days after delivery the patient is perhaps 
seized with a shivering fit, and the nurse is surprised, 
as she protests she has not had the least waft of cold ; 
more cloaths are heaped upon her ; spirituous liquors, 
and hot spices, are given her, to throw off the cold fit, 
which most certainly increase the succeeding hot one. 
A warm room, plenty of cloaths, and warm drinks are 
continued to throw her into a sweat, but have frequently 



58 CHARLES WHITE 

a contrary effect, by increasing and prolonging the 
burning fit, which at last terminates in a most profuse 
putrid sweat, continuing many nights and days without 
giving relief. 

The cold fit sometimes like the paroxysm of an ague 
returns, but at uncertain[i4] periods, and at last ends in a 
continued fever ; at other times no cold fit precedes 
the disease ; it creeps on gradually, and first shews 
itself by putrid sweats, attended with a nausea, or by 
vomitings of porraceous matter, and a looseness. 
What the patient vomits is generally mixed with 
large quantities of bile of a dark colour. The stools 
are sometimes very copious and frequent, and so 
exceedingly putrid as to be offensive all over the house, 
and to convey infection to the whole family : at other 
times the patient is racked with a constant tenesmus, 
and with frequent motions to make water, accompanied 
with swelling, pain, and soreness in the belly, and with 
pains in the head, back, breasts, sides, hips and iliac 
region, with a cough and difficulty of breathing ; there 
is commonly a wildness in the countenance, and the 
head seems hurried, and in some cases the face is 
flushed ; the urine is generally very high coloured, and 
sometimes [15] turbid, with a gelatinous, unequal 
sediment ; but in others it is very pale, or appearing 
like foul cyder, with filaments in it. 

The tongue at first is white and moist and soon after 
is covered with a white fur ; or else it is dry, hard, and 
brown, and afterwards covered with a brownish fur ; 
a brown, or blackish sordes, the consequence of putrid 



i 



ON PUERPERAL FEVER. Cap. I 59 

exhalations, adheres to the edges of the teeth. The 
patient usually nauseates all kinds of food and 
drink, except what is cold and acidulated. The pulse 
at the beginning of the disorder is very little altered, 
only something fuller and quicker, but as the disorder 
advances, it grows quick, small, and creeping, and the 
patient complains of great anxiety, and oppression 
about the praecordia, attended with sighings, lowness 
of spirits, lassitude and great debility. The quantity 
of the lochia is frequently not at all diminished, [16] at 
other times it is very much lessened, what flow are very 
foetid, and in some cases this discharge is totally 
suppressed. 

The breasts in some grow flaccid, the milk abates 
in quantity, and if the disorder is not soon removed, is 
entirely lost ; but this is not always the case. 

If the hot regimen be continued, with vinous spicy 
caudles, hot alexipharmic medicines, volatile alcalious 
salts and spirits, opiates, and a close room so as to keep 
the patient in a perpetual sweat, vibices^ or petechias 
appear, or eruptions either of the white or red kind, 
or both, first upon the neck and breasts, afterwards 
extending themselves all over the body, one crop 
succeeding another [17] till the patient is worn out ; but 
they give no relief, are not in any way critical, nor 
is there indeed any regular crisis in this disorder, except 
the looseness. 

I. Cooper speaking of this fever about the fourth day says * Now, 
if not before some violent pains come on, in the arms, and thighs, 
succeeded by a discolouration of the skin, occasioned by the blood 
corroding and stagnating in the vessels/ — Compend. of Midwifery, p. 21 8. 



6o CHARLES WHITE 

The patient is generally easier after every stool, and 
they seem to give relief. The stools at last are dis- 
charged together vsdth the urine, involuntarily ; 
colliquative sweats, hiccupings, convulsions, &c., 
come on ; and death, vv^hich happens sometimes sooner, 
sometimes later, closes the scene. There are some 
v^ho have died so early as within twenty four hours 
after the first attack, but the eleventh from the first 
seizure, is said to be the day on which the patient 
most commonly dies, though others have lived many 
days longer v^thout recovery. 

This disease was well known to Hippocrates,^ and to 
numberless au[i8]thors who have written since his time, 
and has been styled either epidemic,^ malignant, putrid, 
or inflammatory, and by some a compound of all four. 
It is certainly at all times malignant and putrid, when 



1. Hipp, de Morb. Mulierum, lib. I, sect. 5. 
on Epidemical Diseases, case 4 and 5. 

2. * During the prevalence of epidemic fevers, the recovery of 
women in child-bed is much more precarious than in healthy seasons. 
This is observable in every sphere of life, but for obvious reasons, more 
remarkably in lying-in hospitals ; it has been taken notice of by the 
industrious Dr. Sydenham, and by Tho. Bartholine, and must 
undoubtedly have happened invariably in all ages of the world, though 
it is now better understood in this country, since some of the most 
ingenious of our physicians have devoted their time chiefly to the study 
and practice of midwifery, and the management of those diseases with 
which it is more particularly connected.' — Millar on the prevailing 
disorders of Great Britain, pt. 3, sect, i, p. 332, of the puerperal fever. 

* Nonnunquam post lochiorum suppressionem in febrem incidunt 
puerperae, quae vel in earum quae tum grassantur epidemicarum castra 
transit, vel ab ea sola pendit origine.' — Dissert. Epist. adGul. Cole, M.D. 
op. p. 532. 



ON PUERPERAL FEVER. Cap. I 6i 

suffered to run its course, and frequently at some 
seasons epidemic, and in some situations may properly 
be [19] said to be endemic. Nay if the womb has been 
lacerated, or has received any injury in labour, it is 
sometimes undoubtedly compounded of all five. 
Some have represented it as entirely owing to the 
milk, some to an inflammation of the womb^, and 
many to a suppression of the lochia ; some have 
ranked [20] it amongst hysterical^ disorders, and others 



1. Tissot, in his Avis au Peuple, Eng. edit, by Kirkpatrick, p. 371, 
seems to think that this disorder is an inflammation of the womb, and he 
mentions an extraordinary circumstance not taken notice of by other 
authors, viz. that the belly turns black. Sect. 370 he says, ' The 
inflammation of the womb is discoverable by pains in all the lower parts 
of the belly, by a tension or tightness of the whole belly, by a sensible 
increase of pain on touching it — a kind of red stain or spot that mounts 
to the middle of the belly, as high as the navel, which spot as the 
disease increases turns black, and then is always a mortal symptom, 
by a very extraordinary degree of weakness, an astonishing change of 
countenance, a light delirium or raving, a continual fever with a weak 
and hard pulse, sometimes incessant vomitings, a frequent hiccup ; 
a moderate discharge of a reddish stinking sharp water, frequent urgings 
to go to stool, a burning kind of heat in the urine, and sometimes an 
entire suppression of it.' 

2. ' Femina XXX. annorum, temperamenti sanguineo-melancholici, 
hystericis passionibus in puerperio, & extra illud, saepius, obnoxia, 
tertium gravida, gestationis tempore nee vense sectionem admisit, nee 
exquisite servavit praecepta diaetetica. Primis post partum diebus 
non bene purgata est utero : sed de dolore lumborum, torminibus 
ventris, alvo adstricta, & somno per aliquot noctes inquieto conquere- 
batur. A practice, quem in consilium vocavit, validiores essentiae ad 
pellenda lochia fuerunt datae ; & ad alvum aperiendam uncia dimidia 
salis amari Sedlicensis in aqua simplici soluta est oblata. Inde auctis 
torminibus, nee facta per alvum, nee per uterum excretione, converso 
sanguinis versus superiora motu deliravit, & accedentibus convulsionibus 
extincta est.' — Hoffman, Tom. 3, sect, i, cap. 5, obs. 10 de male 
Hysterico. 



62 CHARLES WHITE 

have called it only a symptom, but all have agreed in 
its fatality/ and the uncertainty of every method of 
cure, both in the rich, and in the poor, who all acquire 
this disorder from simi[2i]lar causes, though by means 
somewhat different. I am informed that the appear- 
ances after death, are those of inflammation and 
gangrene in the intestines, or some of the abdominal 
viscera ; sometimes in the uterus f and in some cases 
when the disease has been of long continuance, it has 
extended to the lungs, and all the neighbouring parts. 
In the cavity of the abdomen, is generally found 
an extravasated serum, mixed with purulent matter, 
and an exsudation appears upon the surface of the 
intestines, glueing them to one another, and to the 
peritonaeum. There is [22] no wonder that these appear- 
ances should be observed, more particularly in the 
abdomen, as the very acrid putrid stools voided in this 
disorder must naturally tend to inflame, and to give a 
•putrescent disposition to the intestines by transuding 
their coats, or being absorbed into their small vessels ; 
and we may conclude, that the same causes which 
produce putrefaction in the abdomen of a dead 



1. * As the disease which is the subject of this Essay occasions the 
death of much the greater part of women who die in child-bed, &c.' — 
Denman on the Puerperal Fever, p. i. 

2. Pouteau in his Melanges de Chirurgie, p. 182, upon opening 
two women who died of this fever in their l)dng-in at the Hospital at 
Lyons says, * En ouvrant ces matrices il ce presenta dans I'une & dans 
I'autre une circonstance qui merite attention ; la tunique interne de 
ce viscere etoit noire & molle : la matrice dans son epaisseur avoit une 
rougeur livide & vraiment gangreneuse.' 



ON PUERPERAL FEVER. Cap. I 63 

body/ sooner than in any other part,[23] will also operate 
in the same manner in the living body, wheresoever there 
is a general putrefactive tendency ; nor need we be 
surprised that the womb itself should be found in a 
gangrenous state when we consider the great distension 
it has undergone, and that it has afterwards suddenly 
collapsed, and has been kept sometime imbued with 
the stagnating putrid lochia. 

It does not appear that this disorder can be ascribed 
to simple inflammation. The patients complain 
chiefly of a tension, soreness and tenderness of the belly, 
and are seldom affected with those excruciating pains 
which generally attend common inflammations of the 
bowels ; [24] but it evidently manifests itself to be of the 
putrid kind, occasioned by human effluvia, by accumula- 
tions of acrid putrid bile, and of a putrid coUuvies 
through the whole intestinal canal and organs of 



I. Sir John Pringle gives us the following note, which he informs 
us he had from Doctor Hunter. ' That the abdominal viscera and 
muscles corrupt the soonest of all parts in the body after death, where- 
fore it is a rule with anatomists to begin their dissections and demonstra- 
tions with those parts which first become offensive. That the quick 
putrefaction here may reasonably be ascribed to the putrid steams of 
the faeces with which all those parts are more or less impregnated, 
hence too the cause of the speedy corruption of the psoas and iliacus 
internus in comparison of the muscles in the extremities. That next 
to the abdominal viscera and adjacent parts, the lungs are commonly 
soonest tainted, whether from the air stagnating in the vesiculse 
bronchiales, or some remains of the perspirable matter that may act 
as a ferment, and hasten the putrefaction. For whoever tries the 
experiment of compressing the thorax in a body that has been dead some 
time, will be sensible of the putrid state of the lungs, by the offensiveness 
of the air that is forced out of them.' — On the Diseases of the Army, 
Appendix, p. 84, 4to. Edit. 



64 CHARLES WHITE 

generation, and is a malignant-^ fever of the same 
genus as the jail or hospital fever. 

Scarce any two authors have described this fever 
alike, and yet I believe [25] their descriptions have truly 
been from what they have seen, but these different 
appearances have been probably owing to a variety of 
management, and to a difference in the constitutions 
of the patients. 

A true puerperal fever is originally caused by a 
putrid atmosphere, &c. not occasioned by either the 
heat of the air, or any hot things taken internally ; but 
notwithstanding this, it may be much aggravated by 
these, and many of the symptoms frequently attending 
it, are entirely occasioned by hot air, and a hot 
regimen. For instance, if a woman of a strong 
constitution, and of a plethoric habit of body, is seized 
with this fever, and spirituous liquors and hot spices 
are given her, she will have a strong hard pulse, and 
the symptoms of inflammation will run so high as to 
indicate the necessity of copious bleeding ; and when 
the fever is farther advanced, a delirium, subsultus [26] 
tendinum, &c., will come on. But if the patient is 

I. Dr. Munro says, * Many authors have reckoned the malignant, 
petechial, and pestilential, to be distinct species of fevers, and have 
treated each under a particular head. But Riverius has very justly 
observed, that they all belong to the same pestilential tribe, and only 
differ from one another in the degree of infection, and violence of the 
symptoms, and that they are cured by the same general treatment, 
and the same medicines.' — On the Dis. of the Military Hospitals, p. 55. 

And in a note he farther says, * The malignant or hospital fever, and 
petechial, seemed to me to be entirely the same disorder, and the 
petechial spots to be only a symptom which appeared sometimes, but 
not always.' — Ibid. p. 56. 



ON PUERPERAL FEVER. Cap. VI 65 

of a more relaxed habit of body, and is kept sweating 
in bed in a warm room, by warm liquids, eruptions 
will appear upon the skin ; and if a woman subject 
to hysterical complaints is seized with this fever, and has 
any large evacuations either naturally, or procured by 
art, a train of hysterical symptoms will succeed. 
And lastly, it must be observed that though all the 
symptoms here enumerated have been seen in different 
patients, yet it must not be imagined that all of them 
ever occurred in the same subject.[27] 



CHAPTER VI [112] 

Of the Prevention of the Puerperal, Miliary, 
AND Milk Fevers 

As soon after the woman is delivered as it can be 
conveniently done, clean linen should be put about 
her, she should be left to the most perfect quiet of 
body and mind, that she may, if possible, get some sleep. 
The child should be removed into another room, and 
no visitors, or other persons, except such as are 
absolutely necessary, should be allowed to enter the 
patient's chamber. A number of people, besides 
preventing repose, foul the air, and render a frequent [ 1 1 3 ] 
supply necessary. From hence appears the disadvantage 
of a small apartment. Where the patient has it in her 
option, I would always recommend a large lofty room 



66 CHARLES WHITE 

upon the first chamber floor, and could wish it (if in 
summer) to have a northern aspect, but if that cannot 
be had, there should be window blinds placed on the 
outside of the windows, for when they are on the inside, 
they do not answer the purpose of keeping out the heat 
of the sun. In this room there ought to be no fire in 
summer, and little or none in winter whilst the patient 
is in bed, unless she has been used to sleep constantly 
with one in her chamber ; for though fires are 
undoubtedly of the greatest service in keeping up a 
circulation of air, yet at the same time a constant fire 
in a small room, when a person has not been accustomed 
to one, may overheat the patient. This I know will be 
objected to by the nurses, upon their own accoutit, 
especially if they are to wake, but waking is [114] what I 
do not approve, except on the first night, and then only 
if the delivery be late in the evening. It will disturb 
the patient much less if the nurse has a small bed in the 
room, but I would by no means suffer the child to 
remain there, if accommodations can possibly be had for 
it in any other part of the house. The patient should 
not be disturbed in the night, either upon pretence 
of giving her liquid or solid nourishment. If either be 
necessary, she will naturally of herself demand it. 

Much mischief is often done by binding the belly 
too tight.^ If there be any occasion for support, a thin 

I. * This disease (the puerperal fever) it must be acknowledged, 
may follow a labor under the best circumstances, but endeavours to 
dilate the os internum, and too hasty a separation of the placenta will 
produce it, and binding the abdomen tight after delivery.' — Denman 
on the Puerperal Fever, p. i8. 



ON PUERPERAL FEVER. Cap. VI e'j 

napkin pinned very slightly round the waist, is all [115} 
that is absolutely necessary, and the sooner this is disused 
the better. But if there really was occasion for strong 
compression, the common methods would be extremely 
inadequate. The compression must necessarily be 
unequal, the large hip bones of women effectually 
preventing such means as these from making an equal 
pressure upon every part of the uterus. 

The thick fustian waistcoats and petticoats usually 
worn during the lying-in, are much too warm. In the 
whole article of dress and bed clothes, nothing should be 
added to what the patient has been accustomed to in 
perfect health. 

In a few hours after delivery, as soon as the patient 
has had a little rest, she should sit up in bed, with a 
bed-gown thrown over her shoulders. If she proposes 
to suckle the child, it should now be laid to her breast, 
whether there be signs [116] of milk or no. This should 
be repeated four or five times a day, but in the night it 
is not necessary either that the breast should be adminis- 
tered, or that any kind of food should be given to the 
infant. 

The patient should lie very high with her head and 
shoulders, and should sit up in bed when she takes her 
food, and as often as she suckles her child, and should 
kneel whenever she has occasion to make water, which 
should be often done. 

This frequent upright posture is of the utmost 
consequence, and cannot be too much enforced. It 
prevents the lochia from stagnating, the stools and urine 



68 CHARLES WHITE 

from being too long retained, and promotes the 
contraction of the uterus, together with that of the 
abdominal muscles. 

Large quantities of caudle, and thick gruel mixed 
with ale, wine, or brandy, [117] are often very pernicious. 
They clog the stomach, and pall the appetite. Strong 
liquors as they are apt to heat, should not be given to 
the patient, unless she has been accustomed to them. 
Thin water gruel, well boiled and strained, panada, 
sago, wort, salep, barley water, to which a small 
quantity of lemon juice has been added ; teas of all 
kinds, but particularly those of bitter antiseptic herbs, 
such as chamomile, or buckbean ; coffee, cocoa and 
chocolate, buttermilk alone, or mixed with spring 
water, imperial, orange, or lemonade, or plain toast 
and water may be allowed, provided none of them have 
been found by experience to disagree with the patient. 
None of these liquors should be given hot, the cooler 
they are drank the better, and they may even be given 
perfectly cold. Toasted bread, sea biscuit, or some- 
thing solid should be taken to prevent faintness, and as 
soon as the patient has an appetite her food should 
consist of [118] boiled bread pudding, boiled fowls, lamb, 
or veal, vegetables and ripe fruit. Too much animal food 
should not be allowed, and it should never be eaten 
oftener than once a day, and then not without bread 
and greens, roots, or some kind of vegetables. The 
North American sago powder, dissolved in boiling water 
forms a most agreeable, transparent, mucilaginous, 
vegetable jelly, which is demulcent, restorative and 



ON PUERPERAL FEVER. Cap. VI 69 

nutritious ; obtunding the acrimony of the fluids, and 
correcting putrefaction ; of a more pleasant taste, in my 
opinion, than salep, and much cheaper than the 
foreign salep, though not so cheap as that produced in 
our own country, and prepared in the manner directed 
by Mr. Moult in the Philos. Trans, vol. 59, p. i. 

Whatever w^ater the patient drinks either alone or 
in gruel, teas, &c., should not be such as is tainted with 
any putrid animal or vegetable substances, which is [119] 
generally the case in all reservoirs of stagnant water and 
in rivers adjoining to large towns. 

Broths,^ or soups made of flesh-meat, especially if 
given warm, are impro[i20]per, as they are apt to throw 
the patient into a sweat, and promote putrefaction. 
If the patient cannot, or does not choose to suckle her 
child, she should be very abstemious in her diet ; but if 
she suckles it, a much greater latitude may be allowed. 

Fruits, vegetables, and all kinds of acid or acescent 
food have generally been denied to nurses, upon a 



I. * The French and many other nations, give their patients 
meat soup, in acute diseases, and after capital operations, and they 
allow them but little bread, or other preparations of vegetable sub- 
stances ; but these soups, without bread, do not nourish the patient 
sufficiently, and tend too much to the putrescent ; and this is one reason 
why more sick die in the French, than in the British hospitals.' — 
Monro on the diseases of the British military hospitals, Note to p. 373. 

Dr. Lind, speaking of a marine hospital erected at Jamaica, upon 
a most unhealthy spot of ground, says, ' The recovery of patients in 
that hospital was observed to be very tedious, and uncertain ; the 
least indiscretion or irregularity brought on a relapse. After a flux 
had been stopped some days, the eating of any sort of food, which 
had a putrid tendency, such as even a mess of broth, would sometimes 
in a few hours bring on a return of the disease, accompanied with all 
its violent symptoms.' — Essay on the diseases of Europeans, p. 174. 



70 CHARLES WHITE 

supposition that they created acidities in the children's 
bowels. This in some constitutions they certainly do, 
but the rule is by no means general. I have known 
nurses abounding in acrid putrid bile indulge freely in 
these kinds of food with great advantage to themselves, 
and with no disadvantage to their infants, as plainly 
appeared by the children's never parting with green 
stools during the time of their being suckled.^ 

The heat of the room ought to be so tempered that 
the patient may neither be chilled with cold, nor yet 
suffer from sweat or burnings. She should be kept in 
that degree of heat that approaches nearest to the 
standard of health. Some have kept themselves in a 
constant gentle sweat, or diaphoresis as it is called, in 
order to prevent a rigor, or cold shivering fit ; but it is 
well known that no degree of heat, let it be ever so great, 
wdll prevent the rigor, either in a puerperal woman, 
or even in a common ague. There have been instances 
of persons having rigors in the hot sweating room of a 
bagnio, and I have been informed that these have been 
the most dreadful ; rigors and even common agues are 
frequent in the hottest climates. The patient's skin 
should be soft, but not [122] so much as moist; her linen 
being damp with sweat will render her liable to catch 
cold ; she will be sensible of every breath of air, and 
cannot rise or even turn herself in bed without danger. 

I. Are not the sour green stools of children oftener owing to weak- 
ness and relaxation in their digestive [121] organs, and the inert quality 
of their bile, than to the acescency of the milk ? and do we not often 
see them change for the worse even though the nurse has made no 
alteration in her diet, nor has tasted any kind of acescent food ? 



ON PUERPERAL FEVER. Cap. VI 71 

The apartment cannot be ventilated, nor even a curtain 
be undrawn ; consequently she becomes weak, the 
fibres are relaxed, and thus a predisposing cause is given 
of putrid fevers. Custom in this I know is much 
against me, as well as in many other particulars ; 
but I have hundreds of evidences to prove that sweating 
is not necessary even in the smallest degree. 

Much mischief appears to have been done amongst 
ignorant people by confounding the ideas of 
perspiration-*- and sweat. The difference between them 
has been remarked by so great a number of authors, 
that quotations would be endless ; it is sufficient for 
common use to observe that perspiration is that 
insensible discharge of vapour from the whole surface 
of the body and the lungs which is constantly going 
on in a healthy state, that it is always natural and 
always salutary ; that sweat, on the contrary, is an 
evacuation which never appears without some 
uncommon effort, or some disease in the system, that it 
weakens and relaxes, and so far from coinciding with 
perspiration, obstructs and checks it. 

With regard to sweating in febrile disorders many 
contrary opinions have [124] prevailed. It was introduced 
with the notion of carrying off by its means the morbid 
matter which was supposed to be the occasion of all 

I. Dr. Home has proved by several experiments that a free 
perspiration does not depend so much upon the heat, as the dryness of 
the air, he says, ' Moisture stops [123j perspiration in a great degree. 
Dr. Hales has observed that moisture has the same effect on the 
perspiration of plants.' — Med. Facts and Experiments, p. 245. 

A little farther he observes, that ' by these two experiments it 
appears that the perspiration is greater in frost than in open weather.' — 
Ibid. p. 246. 



72 CHARLES WHITE 

fevers. Later observation has however found it 
prejudicial in many cases ; and some have gone so far as 
to deny its utiHty in any. I shall make quotations from 
some of these authors^ vi^ho have considered this 
matter the most clearly and particularly. 

I. * Hippocrates relates the cases of some patients, whose fevers 
were terminated after the eruption of sweat, whether that sweat 
really put a period to the disease, or only appeared at its end ; as it 
happened in the instances recorded, lib. i. patient 6. 7. lib. 2. patient 
7. II. 12. in which patients the fever seems rather to be terminated 
by an eruption of blood than of sweat ; for sweat so far as I can perceive 
is not by Hippocrates always proposed as an instrument by which the 
disease is cured, but only as a mark or sign by which its event or 
termination may, with the greatest certainty, be prognosticated. 
For this reason, in those books of his which are accounted genuine, 
he nowhere mentions sudorific medicines ; and even in those works 
which are falsely ascribed to Hippocrates, there is only once mention 
made of a sweat procured or forced by medicines ; for the author of his 
second book of epidemics orders a sweat to be procured by carefully 
covering the patient with the bed cloaths, and exhibiting [125] meal, 
mixed in rich and generous wine, nor does he even prescribe these 
measures as proper to be taken, except in those fevers which arise from 
lassitude, or some other similar cause, such as those commonly called 
diary fevers. 

* Internal medicines for producing sweats were so little in use 
among the ancients, that Celsus has not a single word upon this subject. 
If therefore sweats are of any advantage in fevers of this kind, they seem 
to derive their efficacy from nature alone. During those sweats 
perhaps the peccant matter might be easily dissipated, and carried 
through the skin, either on account of the temperance of the climate, 
or by the good constitutions of the patients, which were not yet 
corrupted by sloth and luxury. But in the present condition of 
mankind, we in vain expect the solution of a disease by sweat, whether 
spontaneous and natural, or procured by art ; and I believe I may 
justly venture to affirm, that in violent fevers the patients are rarely 
restored by sweats alone.' — Friend on Fevers, Comment, i. 

* But whereas the hot regimen is still too much in use, it may not be 
amiss to examine a little more narrowly, how it comes to pass that so 
many ill consequences flow from it. 

' Nature then is scarce ever able to expel the febrile matter by 
sweat, before it has taken up a proper time for its maturation, except 
in the plague ; so that sweats, which of their own accord flow largely 
in the beginning of a disease, do not carry off the fever, but prognosticate 
a long and dangerous disorder, and probably are the occasion of it. 



ON PUERPERAL FEVER. Cap. VI 73 

From the whole we may conclude. [126] 

1. That sweating in bed in a confined atmosphere 
must be very detrimental to a [127] person in health, may 
bring on many disorders, but cannot prevent any. [128] 

2. That sweats are particularly detrimental to 

They likewise render the patient costive in the beginning, and in putrid 
fevers frequently cause a diarrhoea towards the crisis, whereas those 
persons generally escape, and most easily get free from a fever, to whom 
the very contrary of this happens. 

* In these climates there is no necessity that persons in perfect health 
should have a visible moisture on their skin, but in very warm countries, 
in hot days this seems to be of great service. In Egypt during the second 
part of the summer, every one sweats profusely several times a day, 
and at that season the inhabitants always enjoy the most perfect health. 

* Such an error is never more frequently committed than in giving 
what they call cordial and sudorific medicines in the beginning of fevers, 
for this method promises an easy and pleasant cure, and is agreeable 
to the opinion of the vulgar. Custom has made it familiar, and the 
patient finds himself relieved when the sweat begins to flow, and if 
they stop he is abundantly hotter, more thirsty and restless. 

' But sweats which are very easily brought on in the beginning of 
a disease, will frequently quite disappear, as it advances towards the 
height, so as not to be recalled by the warmest medicines ; and though 
they should continue to flow, they will certainly bring along with 
them those bad symptoms which have been mentioned before. 
Although the ancients, the most studious of nature, never admitted 
this method of practice, and the moderns more intimately instructed 
in the sacred mystery of physick always rejected it, yet it is never to be 
expected that the old women who have a licence of slaying mankind 
with impunity should ever suffer themselves to be taken off from their 
method of cure ; but it is to be wished that Physicians who follow the 
guidance of reason, would throw aside their prejudices, and weigh the 
matter with that carefulness it deserves, and banish this pernicious 
method from that art which promises health to mankind.' — Glass on 
Fevers, Comment. 10. 

* Plerumque in principio morborum acutorum nocet (sudor) ; 
rectius tunc succedit, quando facta coctione materies morbi per cutem 
expelli parata est. Ipse tamen per seipsum neque petechias, neque 
miliarem morbum sanat, neque variolas & periculose per calida 
medicamenta quaeritur, ut ne calidus quidem potus nimis tutus fit, 
quem vidi, de mitissmis herbis decoctum, bis intra triduum in delirium 
atrox hominem miliari febre laborantem conjecisse : qui idem 
refrigeratione undique quaesita levatus, denique convaluit.' — Haller. 
Elem. Physiol, torn. v. p. 51. 



74 CHARLES WHITE 

women in the puerperal state, as they render them 
costive, check the discharge of the lochia, relax and 
weaken the patients, and make them so susceptible of 
cold, that the air cannot be renewed, nor the common 
offices of life be performed without danger. 

3 . That sweats are very detrimental in the beginning 
of all low nervous, or putrid fevers, but particularly 
those of lying-in women, which if not in the beginning, 
are always in their termination of one of those classes, 
if they continue any length of time. 

4. That the rigor in the paroxysm [129] of an ague 
is terminated by a sweat, but the continuance of that 
sweat will not prevent a fresh accession. 

5. That when the morbific matter is thrown off by 
the skin, it must be an act of nature ; and the most 
probable means of promoting that end is to keep the 
patient in that kind of heat which nearest approaches 
the standard of health, at the same time promoting a 
free circulation of air, that those morbific particles and 
the human effluvia may not stagnate about the patient, 
but be carried off, and their absorption prevented by an 
effectual ventilation. 

The chamber door, and even the windows, if the 
weather be warm, should be opened every day. There 
should be no board or other contrivance to stop the 
chimney, on the contrary it should be quite open, that 
it may act as a ventilator. The curtains should not be 
close [130] drawn, that the effluvia may have the liberty 
of escaping. Carpets are very useful, as they render 
washing the room unnecessary, for moisture ought as 



ON PUERPERAL FEVER. Cap. VI 75 

carefully to be avoided as heat or cold, therefore it ought 
not to be washed upon any account as long as the 
patient stays in it. The room should be brushed, and 
the carpets taken out every day, to be cleaned and aired. 

The lying-in chamber should in every respect be as 
sweet, as clean, and as free from any disagreeable smell, 
as any other part of the house. The patient should 
often be supplied with clean linen, for cleanliness, and 
free, pure, and in some cases cool air, are the greatest 
necessaries in this situation ; and upon the strictest 
examination it appears evident to me that there never 
was a miliary eruption produced without a sweat, nor 
a puerperal fever without foul air, except in cases where 
violence had been used, either in [131] dilating the os 
internum^ or in the delivery of the child or the placenta, 
or from some very great imprudence. 

The sooner she gets out of bed the better ; this 
should not be deferred beyond the second or third day 
at the furthest, and then if it be vdnter time, it will be 
necessary to have a fire. 

Clean, well aired sheets, should now be laid upon the 
bed, but by no means such as have been lain in since 
their washing. 

If the patient has not every day a stool, one ought 
daily to be procured. The best and safest way of 
effecting this (especially during the first week) is by 
clysters ; for these will not only procure stools, but by 
passing along the arch of the colon, act as fomentations 
to the whole abdomen, without any griping or other 
disagreeable commotions. For this purpose warm 



76 CHARLES WHITE 

water is generally sufficient ; but if the foeces are too 
much hardened, milk, oil, and brown sugar, or [132] the 
decoct, commun. pro clyst, with syrup of buckthorn may 
be administered, nothing of a more stimulating nature 
should be used ; it is better to repeat these clysters, 
in which case their end will certainly be answered. If 
the patient has an unconquerable aversion to these 
applications, or if a clyster cannot be administered 
either upon account of lacerations in the sphincter ani, 
or from any other cause, it will then be necessary to 
give a little manna, lenitive electuary, rhubarb, or 
magnesia. The stools, urine, and foul linen, should not 
be permitted to remain in the apartment. 

If the lochia do not flow so plentifully as may be 
expected, or if they entirely stop, no irritating, forcing 
medicines should be used. They never do any good, 
and are often productive of much mischief.^ If the 
patient is other[i33]wise as well as can be wished, no 
regard needs to be paid to this circumstance. We not 
only find this evacuation very different in different 
women, but even in the same woman in different 
lyings-in, from which she recovers equally well. 
I have frequently known this discharge to stop the 

I. * We have also been taught to endeavour strenuously to remove 
every obstacle to the regular procedure of the lochia. But it unfor- 
tunately happens that almost all the medicines recommended as 
emmenagogues are improper in every inflammatory state of the blood, 
and experience proves that in this case, all the symptoms are aggravated 
by their use. 

* It may not be amiss to observe that either a great, or a little quantity 
of the lochia unattended with other symptoms, is not to be looked upon 
as a disease, or meddled with.' — Denman on the Puerperal Fever, p. 24. 



ON PUERPERAL FEVER. Cap. VI -j^ 

very first day without the least bad consequence. 
If she has other complaints, the causes of those com- 
plaints must be enquired into, and the disorder 
remedied ; if this be done, the stoppage of the lochia 
will be of little or no consequence, and when the 
cause is taken away they will sometimes flow [134] 
again. It is not a primary disease, the effect is mistaken 
for the cause. 

The patient's recovery does not depend upon the 
quantity of the discharge, for the evacuation itself will 
not prevent either the puerperal or miliary fever. 
It is well known that the laborious hard working women 
(who using much exercise, seem to live in a state 
nearly approaching to that of nature) have not so 
large a quantity either of the menses or lochia as the 
more delicate part of their sex, yet they commonly 
enjoy a good state of health, and recover from their 
lyings-in much sooner than others. They are the very 
reverse of those whose fibres are relaxed by a sedentary 
inactive life, and I have frequently observed, that such 
as have the lochia in greatest abundance are most liable 
to putrid fevers. It must however be owned, that after 
these fevers are commenced, stoppages are not 
uncommon. All I would here [135] inculcate is, that the 
danger does not arise from the smallness of the quantity 
of the discharge, but from its stagnation, whereby it 
becomes putrid, and in this state is again absorbed into 
the circulation. When the discharge is great, but 
does not weaken the patient, no remedy is necessary ; 
when it does, an infusion of the external rind of 



78 CHARLES WHITE 

oranges, with the bark/ and the acid elixir of vitriol 
may, during any period of the puerperal state, be given 
with safety and advantage. To these may be added a 
strengthening incrassating diet, blomange, flummery, 
sago, salep, jellies of calves' feet, hartshorn or isinglass. 
When this disorder arises from irritations and spasms, 
occasioned, as is very often the case, by too [136] great 
an acrimony of the fluids, opiates and the tincture of 
roses well acidulated are generally successful. If the 
evacuation should be excessive, provided the patient be 
kept cool, she may be indulged with rest in a hori- 
zontal position, and more powerful astringents must be 
used, such as alum posset, and the lixivium martis, 
given to the quantity of fifteen or twenty drops three or 
four times a day. Linen cloaths dipped in cold vinegar^ 



1. ' The Peruvian Bark has been given to a woman successfully in 
the quantity of a drachm every three hours, two days after her delivery, 
for twenty-four hours, without lessening the lochia ; and it has 
frequently been given to others during their catamenia without the 
least interruption of them.' — Med. Transact., vol. i, article 21, by 
Dr. W. Heberden. 

2. * Injecting cold water into the uterus is recommended by that 
celebrated professor of midwifery at Edinburgh, Dr. Young, but it is a 
remedy I have never tried. " Verum arteriolas rubras constringendo 
ad haemorrhagias sistendas optime accomodatum est frigus. Ad hoc 
efficiendum, applicatio topica, in partis affectae vicinia, maxime 
convenit. In epistaxe, remedium apud omnes notissimum est aqua 
frigida, quae ope lintei, fronti vel nuchae imponitur : nee ullum 
quidem efficacius invenitur. Ne crarius, neque minore successu, in 
menorrhagia adhibetur : interdum enim, multis aliis incassum tentatis, 
aqua gelida dorso, modo supra dicto, applicata speratum auxilium 
praebet. In lochiorum profluvio immodico & periculoso eandem 
multum laudat CI. professor noster Young ; quam in uterum, per 
horae quadrantem, continenter injicere jubet." ' — Tucker Dissert. 
Med. Inaug., p. 21. 



ON PUERPERAL FEVER. Cap. VI 79 

may be frequently applied to the lower part of the 
abdomen. [137] 

If the patient faints^ away she must not be roused by 
volatiles, or anything else applied to her nose, nor by 
wine or other cordials given internally. I have 
frequently known fainting fits put an immediate stop to 
violent floodings, by [138] giving the blood time to 
coagulate in the uterine veins, and large doses of nitre^ 

1. ' And upon this occasion I recollected a remark of Doctor 
Hunter's, which is, " that the faintness which comes on after haemorr- 
hages, instead of alarming the by-standers, and making them support 
the patient by stimulating medicines, as spirits of hartshorn and 
cordials, should be looked upon as salutary, as it seems to be the method 
nature takes to give the blood time to coagulate." ' — Hewson's 
Experimental Enquiry into the Properties of the Blood, p. 68. 

' From this circumstance, that the disposition of the blood to 
coagulate is increased as the animal becomes weaker, we may draw an 
inference of some use, with regard to the stopping of haemorrhages, 
viz., not to rouse the patient by stimulating medicines, nor by motion, 
but to let that languor or faintness continue, since it is so favourable 
for that purpose ; and also that the medicines likely to be of service 
in those cases, are such as cool the body, lessen the force of the cir- 
culation and increase that languor or faintness. For in proportion as 
these effects are produced, the divided arteries become more capable 
of contracting, and the blood more readily coagulates ; two circum- 
stances that seem to concur in closing the bleeding orifices. 

' Besides giving stimulants and cordials to counteract the fainting, 
it is a common practice in many parts of England, to give women who 
are flooding, considerable quantities of port-wine, on a supposition 
that it will do them service by its astringency. But surely, from its 
increasing the force of the circulation, it must be prejudicial in those 
cases. Perhaps many of the remedies called styptics might be objected 
to for the same reason.' — Ibid. 71. 

2. ' It therefore shews how much languor and faintness should be 
encouraged in haemorrhages, and how carefully we should avoid giving 
anything that can stimulate, or rouse the patient ; that the medicines 
that are likely to be of service are nitre and the acids, or such as cool 
the body or have the property of diminishing the force of the circula- 
tion, or of increasing that languor or faintness ; that all anxiety and 
agitation of mind should, as much as possible, be prevented, lest they 



8o CHARLES WHITE 

have often afforded instant relief, [139] which I suppose 
is owing to the power which Mr. Alexander justly 
ascribes to it, of almost instantly retarding the velocity 
of the circulation, and of surprisingly diminishing the 
number of pulsations ; but it should be given immedi- 
ately after being dissolved, as the same gentleman has 
observed, that it then [140] possesses that power in a 
greater degree. In constitutions that are subject to 
acrid putrid bile, nitre is improper, as it generally 
disagrees with the stomach. 

If the discharge of the lochia be moderate, the 
patient should not only sit up often, but should every 
day get out of bed, staying up as long as she can 
without fatigue, and continuing it a little longer every 
day than she had done the day before. A very 
convenient easy chair has been invented, to which a 
foot-board is adapted, not only preserving the legs and 
feet from cold, but by the means of two straps, so 
contrived that the back of the chair may be depressed, 
and the footboard raised at pleasure. By means of this 
contrivance, if the patient is faint or fatigued with 
sitting up, she may be greatly relieved, and her posture 
made as easy as possible. As the chair runs upon castors, 

increase the circulation, that all muscular motion should be avoided for 
the same reason.' — Hewson's Experimental Inquiry, p. lOO. 

Dr Dickson, in the Med. Obs. and Inq., vol. 4, art. 16, p. 220, 
speaking of nitre given in the form of an electuary with conserve of roses, 
says, ' I have found nitre too administered in this manner of singular 
service in uterine hcemorrhages, but only so far, if my observation is 
correct, when there was a feverishness and hardness of pulse ; for in 
other cases the elix. vitriol, acid, given in small quantities, and very 
frequently repeated, was attended v^th much greater benefit.' 



ON PUERPERAL FEVER. Cap. VI 8i 

it may be readily moved, and by its assistance [141] 
the patient may be enabled to continue a long time 
out of bed without inconvenience. 



Let [149] the directions I have given be strictly 
observed, and I will venture to assert that there will be 
neither puerperal nor miliary fever, nor will the milk 
fever be worth notice, except it be her first lying-in. 
This may be said to be a bold assertion. I am well aware 
of the uncertainty of the medical art, and of the difficulty 
of ascertaining facts, especially by those who, neglecting 
nature as their guide, seem rather to take pleasure in 
obstructing her in her operations. I know likewise 
the difficulty there is in bringing patients to conform 
to proper directions, and the still greater one in 
inducing nurses, and other attendants to follow the rules 
which are prescribed them. [150] 

I am not now amusing the public with idle theories, 
and speculative reasonings ; I am treating on an 
affair of consequence, not only to the female sex, but to 
mankind in general. I speak from facts, from facts 
which cannot deceive me, founded upon my Father's 
experience of more than fifty years, and upon my own 
of above half that period. I appeal to the inhabitants 
of this town and neighbourhood, where if I be guilty 
of misrepresentation, I must meet with the imputation 
I deserve. 

It would be easy to produce a long list of successful 
cases ; successful cases avail nothing, where the 



82 CHARLES WHITE 

unsuccessful are concealed. It is evident that by much 
the greater part of the sex will do well, even under the 
worst of treatment. The practitioner therefore can 
only judge from the result of general practice ; and here 
for the sake of the most import[i5l]ant argument I can 
use, I am obliged to refer to a fact, which otherwise 
could scarcely be mentioned without a shew of 
ostentation which I despise. Out of the whole number 
of lying-in patients whom I have delivered (and I may 
safely call it a great one) I have never lost one, nor to 
the best of my recollection, has one been greatly 
endangered, by the puerperal, miliary, low nervous, 
putrid malignant, or milk fever ; nor have any of these 
fevers ended in madness,^ or any other disagreeable com- 
plaint. Some few indeed [152] have had the puerperal 
fever, but this has evidently arisen from non-observance 
of the rules above laid down. Some few, too, have had 
miliary eruptions, proceeding from the same cause, 
though not one, unless my memory greatly fails me, 
ever had what properly might be called a miliary fever. 
Where feverish symptoms have appeared before 
delivery, they have been happily extinguished. The 
reader may perhaps imagine that by a different treat- 
ment disorders may take different forms, and appear 

I. * It is not only in lying-in cases that madness is sometimes a 
consequence of the neglect, or ill-treatment of this fever, for, in other 
persons it too often terminates in that manner. It is therefore well 
worth observing, since experience confirms the fact, that this sort of 
madness, which follows this low fever, will by no means yield to the 
common methods for the cure of madness, because great evacuations, 
as purging, vomiting, and especially bleeding, always heighten the 
disease, and soon either destroy the patient, or bring on an incurable 
foolishness.' — Etherington on Fevers, p. 41. 



ON PUERPERAL FEVER. Cap. VI 83 

under different denominations. That I may not seem 
to shelter myself under so poor a subterfuge, I am 
necessitated to make a further declaration. I never 
lost a patient either during her month, or at any other 
time, where there was the least reason to imagine her 
death was the consequence of her lying-in. It must 
however be remembered, that in this lasvdeclaration 
I speak only of natural parturitions. I would by no 
means be understood to in[l53] elude in this account 
prseternatural cases, or such laborious ones as have 
required the use of instruments ; those of floodings, 
or convulsions, or those in which consumptions have 
taken rise before the patient's time of delivery. I only 
mean likewise those patients whom I have myself 
attended during the time of delivery. After fevers 
have been created I have been unsuccessfully caUed in 
to those delivered by others. I have however the 
pleasure to observe that those fevers, in this neighbour- 
hood at least, have of late years greatly decreased. 
This must chiefly be attributed to a system of manage- 
ment lately introduced, much to the honour of our 
present practitioners, and of those nurses who seem 
sensible of the advantages arising from it ; and I must 
here do my brethren the justice to assert, that I do not 
know a place where midwifery is more successfully 
practised. Perhaps some general causes may contribute 
to this success amongst the poor in this [154] town, viz., 
their eating very little animal food, and living chiefly 
upon vegetables. Potatoes are a principal part of their 
diet, on account of their goodness and cheapness in this 



84 CHARLES WHITE 

country. We have butter-milk likewise in the greatest 
perfection, and it is drank by the common people both 
in sickness and in health. This liquor when properly 
managed has a pleasant acidity, and very happily 
contributes to prevent and cure any disorders arising 
from putridity. In many parts of this kingdom it is so 
ill prepared, that the poor people will not drink it, and 
it is either thrown away or given to the swine. We are 
likewise well supplied with coals, which is an article of 
consequence, as fires prevent moisture, and keep up a 
circulation of air, and there is little danger of the poor 
people keeping such large fires as to be overheated by 
them. Does not the pump water^ of this place by 
being [155] impregnated with selenitical and aluminous 
salts contribute in some degree to prevent putridity, 
whatever bad effects it may have in promoting disorders 
arising from glandular obstructions ? It may be worthy 
of observation that dysenteries are almost unknown 
in this town. 

Is it not one cause of the frequency and fatality of 
the puerperal, jail, hospital, and other putrid fevers, 
in London, that so many of the inhabitants drink, and 
use for most culinary purposes, the New River water, 
which is frequently replete with putrid vegetable and 
animal substances, or the Thames water,^ which is full 
of all kinds of putrid matter ? [156] 

1. Ftdf Dr. Percival on the Pump Water of Manchester, Essays 
Med. and Exp., p. 288. 

2. * Most pump water is as incapable of changing and of being 
spoiled by keeping as distilled water ; for though it be loaded with 
various foreign particles, yet it seldom has any, or at most but a small 



ON PUERPERAL FEVER. Cap. VI 85 

It may seem strange, but it is nevertheless true, that 
the puerperal and miliary fevers are more common and 
more fatal in London than in the country ; and yet 
it must be acknov^ledged that in general the ablest men 
in every branch of the profession resort to the metro- 
polis : but our wonder v^ill cease when we reflect that 
not only the general causes in large populous towns will 
operate, but likewise that the articles of air, diet, 
dress, &c., are left to the management of the nurses in 
that city, who claim it as a kind of prerogative, and it is 
next to sacrilege to encroach upon their privileges. 
Whether this circumstance has been considered in the 
important light it deserves, or whether the success of a 
reformation has been despaired of, I will not pretend to 

proportion of a vegetable, or animal nature, and therefore it will always 
remain the same. This property of water is not so much attended 
to as it ought to be by sailors, who usually supply their ships with river 
water taken up near great cities, and then keep it in wooden casks : the 
necessary consequence is, that it soon putrefies, and most probably 
contributes very much to the occasioning of those putrid distempers 
with which sailors are so apt to be afflicted. Pump or spring water 
would be greatly preferable, and if they could keep this in glass or 
stone bottles, or earthen jars, they would find it, after being carried 
round the world, just the same as when they set out.' — Med. Trans., 
vol. I, p. 19, by Dr. W. Heberden. 

* The great tendency in the Thames water first to ferment, and then 
to become pure, in long voyages is well known, and it is probable that 
this quality is owing to the extraordinary quantity of putrid matter 
with which it is impregnated at the place where it is taken up, viz., 
a little below London bridge.' — Pringle's Appendix, p. 67. 

Sir John Pringle, in his Observations on the Dysentery says, * Having 
observed in my private practice that some were better for drinking 
Bristol water, not only at the spring, but at a distance, I desired one of 
my patients (who had come from the Havannah) to observe whether 
he found any difference between drinking the river water and the 
pump water in this city ; and after some trials he assured me that he was 
less liable to a return of his flux when he used the latter.' — Obs. on the 
Diseases of the Army, p. 285. 



86 CHARLES WHITE 

determine. The nurses in London are a numerous and 
powerful body, and an attempt to reform their ancient 
customs might be looked upon as an open attack upon 
them, a violation of their rights, and an actual declara- 
tion of war. A young man j ust [157] coming into business 
might justly think it too daring to attempt to encounter 
them ; he would in all probability be unequal to the 
task, and his future progress would be stopped, by making 
such powerful enemies. The man in full and established 
business could not perhaps spare so much time as would 
be necessary, for it would require a very frequent and 
constant attendance upon his patients to see that the 
nurses did their duty ; and by such an attempt he 
might lose much, and gain little except trouble and 
opposition. 

But the fatality of these fevers is not confined to the 
metropolis. There are several country towns where 
puerperal fevers are very fatal, particularly the town of 
Northampton, a place otherwise remarkable for its 
healthfulness, and situated in an open, champaign 
country ; and I am acquainted with two gentlemen in 
another town, where the whole [158] business in that 
branch is divided betwixt them, and it is very remarkable 
that one of them loses several patients every year of the 
puerperal fever, and the other never so much as meets 
with the disorder ; but their methods of treating their 
patients, as I am informed, are very different. 

From what has been above remarked, I imagine it 
will appear that where a due observance is paid to 
nature, not only during labour, but for some time 



ON PUERPERAL FEVER. Cap. VI 87 

afterwards, there is not the least danger to be appre- 
hended from natural parturitions ; that most, if not aU 
of those disorders which are usually supposed to be 
peculiarly incident to the puerperal state, are either 
the effects of mismanagement in the accoucheur or 
nurses, or else arise from the patient's own imprudence ; 
that they may in general be truly said to be fabricated, 
and may always, except in lying-in hospitals, be 
avoided. [159] 

In hospitals indeed, where numbers are crowded 
together not only in the same house, but in the same 
ward, the puerperal fever cannot so easily be prevented, 
though the miliary fever undoubtedly may. [160] 



I [169] am afraid no methods will be effectual where 
several lying-in women are in one ward. It will be 
impossible to keep the air pure, dry and sweet, and at 
the same time to accommodate the heat of the ward 
to their different constitutions and symptoms. If 
separate apartments cannot be allowed to every patient, 
at least as soon as the fever has seized one she ought 
immediately to be moved into another room, not only 
for her immediate safety, but for that of the other 
patients. Or it would be still better if every woman 
was delivered in a separate ward, and was to remain 
there for a week or ten days, till all danger of this fever 
was over. 



88 CHARLES WHITE 

Whenever [173] a patient has recovered from this fever 
and is removed into another room, the bedding and 
curtains should be washed, the floor and woodwork should 
be cleansed with vinegar, and it would still add to the 
salubrity of the apartment, if it was stoved with 
brimstone, or what is much more effectual, if explosions 
of small quantities of gun-powder were made in it 
after the manner described by Doctor Lind, which 
driving out the foul air, a fresh current immediately 
rushes in to fill up the void space occasioned by the 
explosion. The Doctor seems to think that the good 
effects of it in purifying ships, or other infected places, 
is owing to the antiseptic vapour arising from it ; but 
is it not more probably owing to the explosion ? 
He says he has found this method effectual in purifying 
the air, and that it is inoffensive to the lungs. The 
steams of warm vinegar applied to the patient's nostrils 
are very refreshing, but fu[i74]migating the wards with 
it as has been advised by many authors, has not I believe 
proved so antiseptic as was at first imagined, which may 
be owing probably to the following cause. 

In distilling vinegar it is very well known that what 
comes over at first is mostly mucilage and water, to the 
amount of a third or fourth of the whole quantity ; 
this is generally thrown away as useless, and the very 
acid parts which are supposed to be productive of the 
greatest good, are not to be raised without a very 
considerable degree of heat. So much watery steam 
therefore being diffused all over the room, may tend to 
increase those complaints it was designed to remedy ; 



ON PUERPERAL FEVER. Cap. VI 89 

for it is universally allowed that heat and moisture when 
joined are the parents of putrefaction. 

I have my doubts in regard to the [175] utility of dry 
or moist fumes, or sprinklings in general, such as 
camphorated vinegar, tobacco, nitre, pitch, tar, 
resinous or aromatic gums, sulphur, or frankincense, 
during the patient's stay in the room. Without the 
free admission of air I am apprehensive they will 
operate to no good purpose. If a sufficient quantity 
of free air be admitted they will seldom be necessary. 
And if by their means the air is either heated or 
moistened, they will certainly be prejudicial ; but all 
these methods may be used with advantage if there be 
no patient in the room.[i76]i 



I . I do not reproduce Chapter VII — ' Of the Cure of the Puerperal 
Fever.' It deals with the management of the cold fit, the burning 
fit, the value of emetics (ipecacuahna and antimonical preparations), of 
clysters, effervescent medicines (salt of wormwood and lemon juice), 
cold acidulated Hquors, etc., the harmfulness of sweating and emmen- 
agogues, and the doubtful value of bleedings. 



A N 



APPENDIX 



TO THE 



SECOND EDITION 



Of Mr. WHITE'S 



TREATISE 



ON THE 



MANAGEMENT of PREGNANT 



AMD 



LYING-IN WOMEN. 



LONDON: 

Printed for Edward and Charles Dilly, in the Poultry. 
MDCCLXXVII. 



APPENDIX 

TO THE 

Second Edition 

The most material improvements which the preceding 
Volume has, I flatter myself, been a means of intro- 
ducing into the management of pregnant and lying-in 
women, are the following, ist. The use of a cold or 
temperate bath during the state of pregnancy, and [2] 
that of giving suck. 2dly. Permitting the shoulders 
of the child to be expelled by the labour pains only, 
instead of hurrying them away forcibly in one direction 
v^dthout suffering them to accommodate themselves to 
the dimensions of the pelvis by making their proper 
turns. 3dly. Allowing the circulation betwixt the 
child and placenta to cease spontaneously, instead of 
immediately intercepting it, as soon as the child is 
delivered, by tying the navel-string. 4thly. Placing 
the woman in an upright position as early after 
delivery, and as frequently as possible. These are all 
points which deserve an attentive consideration ; and 
as an additional experience of four years has enabled 
me to speak of them with still greater confidence, and 
to enforce them by later observations, I shall include 
what I have further to communicate on these subjects, 



94 CHARLES WHITE 

toge[3]ther with some additional remarks upon the 
puerperal fever, in an appendix. 

I. In the body of this work I have strongly 
recommended the use of the cold, or rather temperate 
bath in preventing miscarriages, and many other 
disorders incident to the pregnant state. I can now 
confirm the efficacy of this preventive remedy from 
ample experience, in a great number of different 
constitutions. So efficacious, indeed, it has proved, 
that I have not known a single instance of its failure, 
except where the patient has received some violent 
injury. This was the case with a lady who miscarried 
in consequence of a fall down stairs ; but returning 
afterwards to the use of the bath, she conceived again ; 
and continuing the bathing the whole period of 
gestation, became the happy mo[4]ther of a fine child, 
though she had before met with frequent disappoint- 
ments. 

I must here likewise confirm what I before observed 
concerning the excellent effects of the same remedy 
in increasing the secretion of milk, and preserving the 
health during the time of suckling ; and particularly 
in preventing the colds to which nurses are so liable. 
Several ladies of my acquaintance are so sensible of 
these benefits, that they constantly bathe three or 
four times a week while pregnant and giving suck, 
intermitting it only during the month of their lying-in, 
and some scarcely so long. 

It is a just and important observation which 
Dr. Hunter makes in his lectures, that " although 



APPENDIX 95 

women usually miscarry at eleven or twelve weeks, 
the foetus has [5] generally been blighted, or removed 
out of the circulation at seven or eight weeks." This 
fact suggests an essential remark concerning bathing, 
that if it be not begun before the term at which the 
uterine fruit is generally blighted, no good can be 
expected from it in preventing miscarriage. 

II. The common practice of pulling at the child's 
head the instant it is born, and thereby preventing 
the shoulders from making their proper turns, is 
productive of more bad consequences both to the 
mother and child than might at first be apprehended. 
The child is a sufferer, as well by overstraining the 
muscles of the neck in the action of forcibly dragging 
it forwards, as by the pressure of the shoulders against 
each side of the chest, whilst they pass through the 
bones of the pelvis in a wrong direction. It is [6] 
obvious that by these means its shape will be greatly 
altered, perhaps so as never perfectly to recover itself ; 
which may lay the foundation of various diseases. 
The effects on the mother are probably more pernicious 
in stretching and relaxing the ligaments of the womb, 
the internal coat of the vagina, and the other parts 
subservient to generation ; whereby prolapsuses of 
the vagina and anus, and a train of other disagreeable 
complaints may be occasioned. But there are, I am 
persuaded, more immediate bad consequences accruing 
to the mother. By forestalling nature in the expulsion 
of the child, the pains are so weakened as to be rendered 
insufficient to expel the placenta. Before I became 



96 CHARLES WHITE 

sensible of the absurdity of this mode of practice, I 
was frequently obliged to extract the placenta by- 
manual operation ; but for many years past this has 
never [7] happened to me in any case where I myself 
had delivered the child. Gently pulling at the funis 
has always proved sufficient for the purpose ; and 
from analogical reasoning I should conclude that even 
this slight assistance would be unnecessary, were not 
the generality of women in our age and country in a 
state very unfavourable to the full exertion of their 
natural powers. By the too hasty delivery of the 
child likewise, afterpains are occasioned, as by this 
means the mouths of the sinuses or uterine veins are 
permitted to close too suddenly. 

III. In the year 1775 a gentleman in London, of 
deserved eminence in his profession, printed a short 
paper which he intended to put into the hands of 
every practitioner of midwifery with whom he was 
acquainted. Its purport was to recommend a method, 
which he supposed [8] to be new, of managing the 
navel string at the time of delivery. He had com- 
municated his observations on this head to his pupils 
the winter before ; and had shewn the paper in 
manuscript to several medical gentlemen who all 
approved of it, as inculcating a new and useful mode 
of practice. A few days after the paper was printed, 
he was much surprised when shewn by a student that 
I had recommended in such explicit terms, and from 
similar motives, the same practice. He immediately 
wrote me a very friendly letter, and inclosed one of 



APPENDIX 97 

the papers. As many of my readers may not have 
seen this Httle tract, and the point proposed is very 
ingeniously maintained by the author, I shall without 
apology reprint it entire. 

[9] An observation on the management of 

CHILDREN AT THE TIME OF BIRTH. 

London : printed for J. Walter, charing cross, 1775 

' It hath been a matter of the most serious con- 
sideration to those who have had the care of very 
young children, to see so great a number born dead, 
or die after an imperfect existence of a few hours or 
days. With a view of preventing these accidents, 
which though sometimes unavoidable, have more 
frequently seemed to be owing to mismanagement, 
I presume to recommend a method, which, as far as 
my experience enables me to judge, is much preferable 
to that which is usually followed.' 

[10] ' To explain my opinion, I will call the life 
of a child in utero fetal life, and the Hfe which is 
consequent to respiration, animal life.' 

' From very hard and tedious labours, and from 
other causes, children will sometimes be born without 
any apparent signs of life. But if we apply the hand 
to the side ; or examine the navel string, we shall 
often be sensible of a strong and regular pulsation in 
the heart, or in the arteries of the navel string.' 

' Under such circumstances it hath been thought 
proper to treat the children as apoplectic ; and with 



98 CHARLES WHITE 

a view of preventing those ill consequences, which 
were apprehended from the accumulation of blood 
in the brain, it has been judged necessary to divide 
the navel string, and to suffer the vessels to discharge 
a small quantity of blood.' 

[11] * This method I have repeatedly tried, and the 
almost uniform consequence has been the death of the 
child. In many instances, when children have breathed 
or even cried, on tying the navel string they have 
drooped and died, or afterwards have been recovered 
with great difficulty.' , 

' Nor shall we be surprised at the event, if we 
consider that in such a state, the life of the children 
was merely fetal, in the same manner as if they were 
yet in uteroJ 

' By dividing or tying the navel string, the fetal 
life was instantly and entirely destroyed, and the 
children not having acquired animal life must inevit- 
ably perish.' 

' The fetal life and the animal life, never exist in 
perfection at the same [12] time ; but as the animal 
life improves, the former gradually declines, and is 
at last destroyed.' 

* Thus when a child is born with signs of the most 
perfect life, there is a pulsation in the arteries of the 
navel string. If the child should continue to breathe 
or to cry, this pulsation abates, and in a short time 
entirely ceases.' 

' Should a child be born very feeble, and neither 
breathe or cry, the pulsation of the arteries of the 



APPENDIX 99 

navel string, may nevertheless be often perceived, 
till the child acquires perfect animal life, or till it be 
entirely dead.' 

' It is curious to observe the manner in which 
the pulsation of the arteries of the navel string declines. 
It first ceases in that part which is nearest to the 
mother, and the column of blood is thrown at every 
stroke of the heart of the child, [13] to a less distance ; 
so that at last, the blood which circulated in the fetal 
part of the placenta, resides in the child.' 

' The pulsation of the arteries of the navel string, 
proves the existence of the fetal life. The existence 
of the fetal life proves the imperfection of the animal 
life. While the animal life is imperfect, the fetal 
life ought not to be destroyed.' 

' The navel string therefore should never be 
divided or tied, while there is any pulsation in its 
arteries.' 

* Another method has been advised for the recovery 
of children born apparently dead. Instead of dividing 
the navel string, it has been recommended to press 
the blood contained in it from the mother, towards 
the child.' 

' But this method may produce inconveniences of 
another kind ; for if [14] much force be used, it seems 
possible, absolutely to prevent or to suppress the 
action of the heart of the child. As we are ignorant 
whether the inactivity of the heart proceeds from a 
defect or an excess of blood, it is not prudent to 
interfere with the efforts or proceedings of nature, 



100 CHARLES WHITE 

lest we should impede or interrupt rather than forward 
her operations.' 

' I have only considered the treatment of children 
newly born, as favourable or unfavourable to their 
immediate recovery. It is not however unreasonable 
to suppose that the wrong management of children at 
the time of birth, may be the cause of many of the 
diseases to which they are subject. For if they are 
prevented from acquiring perfect animal life, and are, 
immediately after birth, deprived of a certain quantity 
of blood, which may, at least, be esteemed the medium 
by which life is preserved, we cannot wonder that 
they are more liable to [15] diseases, and less able to 
struggle with the attending danger.' 

' I should not hesitate to declare my opinion, that 
many of those diseases of more advanced age, which 
have been esteemed hereditary, may have been 
occasioned by imprudent management at the time 
of birth ; for those constitutions must necessarily be 
infirm which were never in possession of perfect life.' 



IV. The presence or absence of the puerperal fever 
being, as I conceive, very nearly connected with the 
maintenance of a horizontal or an upright position 
after delivery, I shall under this head comprise what 
I have to add concerning both these subjects. 

Writers are still much divided in their opinions of 
the cause, and even of the nature of the puerperal 
fever ; some [16] ranking it under the class of inflam- 
matory, some of putrid diseases, some calling it a 



APPENDIX loi 

mixture of both, and some a fever fui generis. The 
very attempt to class it has been attended with some 
disadvantages by rendering the difference of opinion 
concerning it greater, and what is worse, by influencing 
practice. Dissections themselves have not assisted 
much in clearing up this matter, as the appearances 
have not been always similar, and different conclusions 
have been drawn from the same appearances.^ It is 
obvi[i7]ous that till some greater certainty be obtained 
with regard to the cause and nature of this disease, 
all attempts towards a rational method of prevention 
or cure will be vain. 



I. The following observations of my worthy friend Mr. J. Hunter 
may not perhaps be here improperly introduced. 

* An accurate knowledge of the appearances in animal bodies that 
' die of a violent death, that is, in perfect health, or in a sound state, 
' ought to be considered as a necessary foundation for judging of the 
' state of the body in those that are diseased. 

' But as the animal body undergoes changes after death, or when 

* dead, it has never been sufficiently considered what those changes are ; 

* and till this be done, it is impossible we should judge accurately of 

* the appearances in dead bodies. The diseases which the living body 

* undergoes (mortification excepted) are always connected with the 

* living principle, and are not in the least familiar to what may be called 

* diseases or changes in the dead body : without this knowledge, our 

* judgment of the appearances in dead bodies must often be very 

* imperfect, or very erroneous ; we may see appearances which are 
' natural, and may suppose them to have arisen from disease ; we may 

* see diseased parts, and suppose them in a natural state ; and we 
' may suppose a circumstance to have existed before death, which 
' was really a consequence of it ; or we may imagine it to be a natural 
' change after death, when it was truly a disease of the living body. 
' It is easy to see therefore, how a man in this state of ignorance must 
' blunder, when he comes to connect the appearances in a dead body 

* with the symptoms that were observed in life ; and indeed all the 

* usefulness of opening dead bodies depends upon the judgment and 

* sagacity with which this sort of comparison is made.' Phil. Trans, 
vol. 62, p. 447 and 448. 



102 CHARLES WHITE 

There are, however, some particular [18] symptoms 
attending it, which if accurately investigated, may 
greatly assist our inquiries. The most distinguishing 
inseparable symptom of all others is the quickness^ of 
the pulse, whatever other [19] quality be joined to it, 
which constantly occurs whenever this fever exists in 

I. ' The pulse has almost an invariable and unusual quickness 
from the beginning.' 

Denman. 

' In the cold fit the pulse was quick and small, and the pulsations 
so feeble and indistinct, that sometimes I was hardly able to number 
them exactly. When the hot fit came on, though it was then more 
full and distinct, it still remained quick, but was seldom hard or strong, 
except in a few instances, where the patient was young and plethoric. 
In general, it would beat from ninety to one hundred and thirty-seven 
strokes in a minute.' 

Leake on the Child-bed Fever, &c., p. 45 & 46. 

* As they became more and more exhausted, and within a few 
hours of death ; the pulse, which was exceedingly quick, and almost 
imperceptibly weak, at last was insensibly lost in a tremulous flutter.' 

Ibid, p. 50. 

* The pulse, in general, is quick and weak ; though sometimes it will 
resist the finger pretty strongly. At the beginning of the disease, it 
seldom beats less than a hundred strokes in the space of a minute ; 
and from this number, I have found it run on to one hundred and 
sixty.' 

Hulme on the Puerperal Fever, p. 5. 

* Nay, so infallible is the beat of the pulse, with respect to number, 
that though all the other symptoms should abate, and the disease seem to 
be gone off, yet if the pulsations do not decrease in proportion, a 
relapse, or some other disorder, is to be feared. 

* A diarrhoea coming on at the beginning, if followed by a slower 
pulse, prognosticates safety. But if after evacuations by stool, whether 
procured by nature or art, the pulse should not become slower, it is to be 
reckoned as one of the most dangerous symptoms.' 

Ibid, p. 31 & 32. 

* They are commonly taken as with an ague fit, there is a strong 
shivering with a great heat, which is succeeded by a pain in the limbs 
and back, and a violent hurrying pulse.' 

Hunter's M.S. Lectures. 



APPENDIX 103 

any alarming degree ; and from which the degree of 
danger may be estimated more certainly than from 
all the other symptoms put together. This 
immode[20]rate quick pulse is not the constant 
attendant of inflammatory, putrid, nervous, or eruptive 
fevers ; but every surgeon conversant with business 
knows that it never fails to attend absorption of matter 
from abscesses or ulcers, whatever be the other con- 
comitant symptoms, or the quality of the matter. The 
physician also knows it is constantly present in ulcers 
of the lungs, and other internal parts of the body. 
In lumbar abscesses, and those of the larger joints, 
it is no uncommon thing for the patient to remain 
in a state of perfect health till the abscess be opened 
either by art or nature, and the airs gets admission. 
But in a few days after this, pain, soreness and tender- 
ness of the neighbouring parts, or perhaps of the 
whole body, are perceived ; a fever supervenes, some- 
times preceded by cold shiverings, and succeeded by 
burning and sweating ; at other times creeping on 
insensibly, but [21] always accompanied with an 
immoderately quick pulse : a diarrhoea and pains in 
the abdomen frequently follow ; and the progress of 
the disease is so rapid, that sometimes in ten or twelve 
days, notwithstanding the use of every remedy, death 
closes the scene. In crowded hospitals these symptoms 
occur with much greater violence than in private 
practice. If the diseased part be so situated as to ^be 
removeable by amputation, and this operation be 
performed before absorption has taken place, or has 



104 CHARLES WHITE 

proceeded too far, all this train of symptoms may be 
either entirely obviated, or removed by it ; and I have 
seen many cases in which, after the patient, from too 
great delay, had been brought to the brink of the grave, 
the application of sponge to the stump, according to 
the method described by Dr. Kirkland, has occasioned 
a perfect recovery ; the quickness of the pulse being 
immediately abated, and all the other symptoms 
allevia[22]ted, as soon as the sponge by imbibing the 
acrid or putrid matter had prevented its absorption. 

Let us now inquire what further circumstances there 
are, besides that of the quick pulse, to make it probable 
that the puerperal fever is occasioned by absorption. 
Notwithstanding the several writers whose attention 
has been of late so much excited by this fever have 
differed considerably concerning the cause of the 
disease, and the method of cure, they have certainly 
observed its appearances with great accuracy, and 
described them with equal minuteness and fidelity. 
Their observations may therefore be referred to as 
sufficient authority, and the following are of much 
weight in the opinion I mean to establish. 

Dr. Denman^ says ' she also feels [23] great pains 
' in the back, hips and groins, and sometimes in one 

* or both legs, which swell, appear inflamed, and are 

* exquisitely painful.' A little further he says, * In 
' some there will be a translation of the disease to the 

* extremities, where the part affected will become 
' inflamed, and a large abscess be formed.' In 

I. Essay on the Puerperal Fever, 2d Ed., p. 9. 



APPENDIX 105 

another place he says, ' Should abscesses be formed in 
' the breasts, they are always much lamented, but 
' there is great reason to conclude, that they prevent 

* more grievous and dangerous complaints.' 

Dr. Leake says^ ' some of those who survived 
' recovered very slowly, and were affected with 
' wandering pains, and a paralytic numbness of the 
' limbs, like that of the chronic rheumatism. Some 
' had critical abscesses in the mus[24]cular parts of the 
' body which were a long time in coming to suppuration 

* and when broke discharged a sanious ichor.' 

Again, * Those who were seized with this fever 

* were not subject to abscesses of the breasts, and of 

* those who happened to have such abscesses, I have 

* never known one to die ; neither are they subject 
' to a diarhcea, or much symptomatic fever, although 
' the pain attending a suppuration of the breast is 

* often very acute.' 

If to these considerations we add, that as the 
puerperal fever is more fatal in large cities and crowded 
hospitals than in places where the air is more open 
and pure, so is the fever occasioned by absorption 
of matter — that as the former is more fatal in some 
peculiar constitutions of the air than in others, so is 
the latter — that as the puerperal fever does not 
[25] appear till after delivery,^ so neither does absorption 
of matter from an abscess till it be opened and the air 

1. Practical Observations on the Child-bed Fever, 2d. Edit., p. 59. 

2. ' Till such a change is produced, women are not subject to this 
fever ; for I have observed, that those with child, who assisted the 
nurses in attending the sick, were perfectly free from it, even when it 



io6 CHARLES WHITE 

have access — we may, I think, with a good degree of 
certainty conclude that the absorption [26] of matter 
is the immediate cause of the puerperal fever, as well 
as of that consequent upon abscesses and ulcers. This 
matter is either carried off by some of the emunctories, 
as by stool, which is the most frequent, by a fresh 
flow of the lochia, or by sweat ; or else it is deposited 
upon some part of the body. If in the cavity of the 
abdomen, upon the lungs,^ [27] the liver,* or upon 
any of the viscera, it generally proves fatal ; if upon 
the breasts, the limbs, or any of the external parts, 
the patient always recovers. 

Let us next enquire what is the source of the matter 

was most rife ; but being delivered, several of them sickened soon 
after, and were affected with the same symptoms as the rest.' 

Leake, p. 88. 

Some are of opinion that there are not wanting instances of the 
puerperal fever being formed before delivery : but may not these 
suggestions arise from sometimes observing cold shiverings before and 
during the time of labour ; and if a puerperal fever come on soon after 
delivery, might they not conclude that those cold shiverings were 
symptoms of that fever ? But these I have so frequently seen withouv 
the puerperal fever supervening, or the least bad consequence ensuing, 
that I am certain they are not to be depended on. Women however 
before delivery are nor exempt from other fevers, and after delivery 
those fevers may change their type and degenerate into the puerperal ; 
nay, I even think it more than probable that if there be a fever of any 
kind at the time of delivery, it may occasion an absorption after delivery, 
and so bring on one of the puerperal kind. 

3. A cough, shortness of breathing together with pleuritic and 
peripneimionic symptoms frequently occur in this disease, and morbid 
appearances in the chest have been found upon dissection. 

* It is almost needless to remark that this fever must, of course, be 
complicated with any disorder that the patient might happen to 
labour under at the time of child-birth. The chief that I have met 
with in this way of any consequence, hath been the phthisis pulmonalis. 
If any disease hath taken its immediate origin, as it were, out of the 



APPENDIX 107 

thus absorbed. That the increased bulk of the uterus 
in the latter months of pregnancy should, by its 
pressure on the intestines, obstruct the free discharge 
of the excrements, may readily be conceived, and is 
known, by every practitioner, frequently to happen. 
Dr. Denman^ has a very just obser[28]vation relative 
to this. Speaking of the stools in the puerperal fever, 
he says, * they are very foetid, of a green or dark brown 
' colour, and working like yest, and it is remarkable, 

* that after the long continuance of the looseness, 
' when the patient has taken little nourishment 
' large and hard lumps of excrement will be sometimes 
' discharged ; which one might suspect to have been 

* lying in the bowels a long time before delivery.' 
He is so particular in this observation, that he repeats 
it in another place. 

puerperal fever, and been combined with it, it hath been the peri- 
pneumony. I have met with several instances of this kind.' 

HuLME, p. 15. 

' Both lobes of the lungs were inflamed, and somewhat black, 
particularly in their most dependent part.' Ihii. p. 41. 

* adhesions of the lungs to the pleura ; a collection of putrid 

serum in the thorax, and matter under the sternum, as in the case of 

Harriot Trueman on enquiry of the patient's friends, I could 

not find that she had ever been in the least subject to any complaint 
in the breast.' 

Leake, p. 93. 

4. ' In una, quantum comperi, jecur erat mollis, enormis, et 
postquam perscissum est, abcessum continere repertum.' 

Diss. Med. Inaug. de Febre Puerper, 
PatT. Keary Edin. 1774, P* ^* 
Dr. Hulme, p. 43, says, * The liver was of an extraordinary magni- 
tude ; in the right lobe was found a very extensive abcess.' 

5. Ih., p. 13. 



io8 CHARLES WHITE 

The horizontal position to which women are so 
frequently confined after delivery, greatly favours an 
absorption of the lochia. As this matter seems but 
imperfectly understood, no proper distinction having 
been made between the absorption and obstruction of 
the lochia, I shall beg the readers patience while I 
attempt to give my ideas of it somewhat at large. 

[29] Writers agree that the puerperal fevers attacks 
indifferently persons who have had a small, or a large 
discharge of the lochia. This is a well-founded fact ; 
but from hence they have concluded that the lochia 
can have no share in producing the disease — a 
conclusion to which I cannot assent. In other cases 
it is constantly found that matter will be absorbed, 
whether the discharge be small or great ; and, what 
may seem extraordinary, it is frequently seen that 
where the discharge is in the largest quantity, the 
absorption is most considerable. But absorption may 
in all cases be increased, and in some entirely caused, 
by such an unfavourable position as may occasion the 
matter to lodge in a wound, where growing acrid it 
will produce inflammation and fever by its irritation. 
By the application of sponge, an incision in the most 
depending part, or mere alteration of position, these 
symptoms frequently soon disappear ; the matter 
becomes more laudable, and is even diminished in 
quantity. We shall pre[30]sently see how these 
observations apply in the puerperal fever. 

That accurate anatomist. Dr. Hunter, has discovered 
the false or spongy chorion, called by him the caduca 



APPENDIX 109 

or memhrana decidua, to be a lamella or efflorescence 
of the womb, which peels off from it like a slough at 
each successive birth. It is an opaque membrane, 
thicker than the true chorion, and exceedingly tender 
in its texture, being hardly firmer than curd of milk 
or coagulated blood. It is however vascular, having 
vessels which carry red blood, from the uterus. It is 
not to be injected by injecting the placenta, being 
not a foetal, but an uterine part. After delivery, the 
greatest membrane is left behind, grows putrid, 
gradually dissolves, and comes away in a fluid state 
along with the cleansings. It frequently however, is 
so long in separating, that on dissection^ of several 
who have died of [31] the puerperal fever, the inside 
of the uterus has been found lined with it ; and it 
has been of so black a colour, that the womb itself has 
been supposed to be mortified, till the mistake was 
discovered by wiping off this substance. Thus we 
have a matter entirely fitted for absorption ; and as 
the communication between the mother and child 
is carried on not by continuity of vessels between 
the placenta and uterus, but a reciprocal absorption 
of blood by means of patulous orifices, we may conclude 
that the womb is an organ of all others the most 
favourably formed to absorb. 

That patients in this fever should generally complain 
of pain and soreness at the lower part of the belly ; 
and that the omentum, peritonaeum and intestines 

I. See Leake, p. 75 & 179. 



no CHARLES WHITE 

should, frequently, be first and principally affected, 
and on dissection be found inflamed, suppurated or 
gangrened, might naturally be expected from their 
contiguity to the source of the absorbed matter. 
[32] These are the common consequences of the 
deposition of acrid matter upon a tender part. But 
the inflammation excited in this manner in a relaxed 
habit, and happening frequently after a considerable 
loss of blood, is very different from one occasioned by 
obstructed perspiration, in a plethoric habit, where no 
considerable evacuation has preceded. Dr. Leake 
relates the case of Sarah Evans, p. 224, who was of a 
very deHcate irritable habit and lax fibres ; she was 
seized with this fever on the third day after delivery, 
when her skin was moist and her pulse quick and 
weak; she died on the 12th day. On opening the 
body, evident marks of inflammation appeared, 
particularly in the abdomen ; a great part of the 
omentum was destroyed and converted into matter, 
and what remained was become gangrenous, &c. — 
The Doctor makes the following remark, ' Where the 

* pulse was extremely soft and weak and the circulation 
' languid ; it is difficult to account [33] for so sudden 

* and high a degree of inflammation as to produce a 
' collection of matter, or any inflammatory affection 
' of the abdominal viscera, but so it was.' 

In another place, he says, ' Considering the languid 

* state of the patient, and the weakness of the pulse, 

* even in the beginning of this fever, I was surprised 
' to find that the inflammation had sometimes run so 



APPENDIX III 

* high, and made so rapid a progress as to produce 

* matter in the abdomen, so early as iht fourth ox fifth 

* day after the first attack ; as will appear in the case 
' of Harriet Trueman.'^ 

He also observes,^ * that in the winter months, when 

* the child-bed fever began, the weather was observed 
' to be remarkably mild and moist, with a warmer 
' temperature of the air than was natural to the 
' season.' But it is [34] well known that true inflam- 
matory disorders prevail most in cold dry easterly 
winds. 

In regard to the prevention and cure of this fever, 
there is not, I believe, a man of eminence in the 
profession who is not thoroughly convinced of the 
necessity of pure, free, and even cool air ; though 
perhaps their directions on this head are seldom so 
strictly put in execution as might be wished. But 
there is another point of practice which is by no 
means hitherto settled ; this is the position of the 
patient for some time after delivery. Several of the 
first accoucheurs and principal nurses in London keep 
their patients in bed for five or six days, or more, 
without ever permitting them to get out of it, and 
what perhaps is worse, without suffering them to sit 
up in bed, or even raise their heads from the pillow. 
And one gentleman, deservedly of high character in 
the profession, in a late publication has declared, 

1. Leake, p. io6. 

2. Ibid, p. 37. 



112 CHARLES WHITE 

* that in his own practice he [35] has seen more frequent 
instances of the puerperal fever from early sitting up 
than from all other accidental causes united.' Were 
this, however, the real cause of puerperal fevers, it 
would be astonishing that any of my patients should 
escape them, as I constantly direct them to sit up in 
an hour or two after delivery, and to repeat it as 
frequently as possible, and even to get out of bed in 
less than twenty-four hours ; and it is seldom that 
they exceed this period. One lady, indeed, whom I 
attended in two lying's-in, lay in bed five days each 
time, and in one of them was for the most part confined 
to a horizontal posture ; and in that she had a puerperal 
fever ; whereas this disease has very rarely occurred 
among others whom I have delivered, and has never 
once proved fatal. Perhaps in London it may be 
thought early to sit up in one day after delivery, or 
to get out of bed in two or three. Now if a horizontal 
position has been constantly maintained for that time, 
and the seeds of the puerperal [36] fever have been 
thereby sown, the sudden change of posture and of 
cloathing may perhaps make it shew itself somewhat 
sooner than it would otherwise have done ; and this 
I think I have seen. 

I have taken some pains to inquire both of the 
gentlemen of the faculty, and the most intelligent 
nurses, whether they had other reasons besides that 
already mentioned for keeping their patients so long 
in a horizontal posture ; and as far as I can learn, 
early sitting up occasioned, as they imagined, a prolapsus 



APPENDIX 113 

of the vagina, or bearing down, as it is commonly 
termed. But I have already declared my opinion that 
this complaint is generally owing to a quite different 
cause, the forcible extraction of the shoulders of the 
child : and I can affirm in the most positive manner, 
that early sitting up has never produced it in the 
slightest degree, in those whom I have delivered. 

[37] That a horizontal position should promote that 
absorption of matter which I consider as in great 
measure the cause of puerperal fevers, will appear 
probable from various considerations. The weight of 
the uterus in this posture carries it close to the vertebrae, 
and causes its sides to approach each other, so as to 
render its figure flatter ; by which means its contraction 
must be impeded, and consequently the expulsion of 
its contents retarded. The discharge of the lochia, 
too, is not, in this case, assisted by gravitation ; hence 
they will be apt to lodge and stagnate in the transverse 
rugae of the vagina. Whereas an upright position 
produces effects the contrary to these. The uterus 
pressing forwards upon the soft parietes of the abdomen 
will meet with no obstacle to its contraction ; and 
the lochial discharges, finding a ready exit by a 
depending orifice, will drain off as soon as they have 
acquired sufficient fluidity. 

[38] An observation from natural history may be 
adduced in confirmation of this idea of the different 
effects of an upright and a horizontal posture. No 
quadrupeds are found to menstruate, except some of 
the monkey tribe ; and of these, according to that 



114 CHARLES WHITE 

eminent naturalist Mr. Buffon,i only such as either 
habitually or occasionally use an erect posture in sitting 
or walking, are subject to this periodical discharge. 

By the mode of practice which it has been the 
purpose of the foregoing treatise to inculcate, I have 
. hitherto been able either to prevent, or if called in 
time to cure the puerperal fever ; but when it [39] 
exists in that malignant endemic form in which it 
sometimes appears in a lying-in hospital, I fear no 
method, as yet proposed, will be sufficient to stop its 
ravages. Under these deplorable circumstances, one 
remedy, which has not, I believe, been mentioned by 
any writer on the subject, might be tried without the 
imputation of rashness. This is a bath of such degree 
of temperature as only to give a gentle shock. Warm 
bathing has been used without success. Dr. Leake^ 
says, ' One would have imagined that the zuarm bath 
* bid fairer to answer this intention than anything 
' else, as it acts like a universal fomentation applied 
' to the surface of the body ; and the rather since it 
' has been found to procure almost instant ease in 
' other disorders of the bowels ; but to the confusion 
' of all theory, in those cases where it was tried, it by 
' no means answered my expectation ; and from [40] 

1. * Le Gibbon Le Magot &c. Les femelles sont comme les 
Femmes, sujettes a une ecoulement periodique de sang/ Tom. 14. 

' Le Coaita, L'exquime &c. Les femelles ne sont pas sujettes a 
I'ecoulement periodique/ Tom. 15. 

* SiMiA Femina menstruat.' 

Linnaei Syst. Nat. Vol. I p. 25. 

2. Ibid, p. 117. 



APPENDIX 115 

' what I could learn, succeeded no better with others : 
' for the greatest part of those died for whom it was 
' directed.' That a temperate bath might prove 
efficacious in preventing the diseases to which lying-in 
women, from too delicate treatment, are liable, we 
have some reason to conclude, from the practice which, 
both in ancient and modern times, has prevailed in 
many parts of the world, of bathing immediately after, 
and in some before delivery, in water of the common 
temperature. Some examples, which might easily 
have been multiplied, of the prevalence of this custom, 
are inserted in the notes.^ Whe[4l]ther, while the 

I. With respect to ancient testimonies of this practice, we have 
the following passage in the Andrian of Terence, Act III, Sc. 2. 

LESBIA. 

Adhuc Archillis quae adsolent, quaeque oportet 
Signa ad salutem esse, omnia huic esse video. 
Nunc primum fac, isthaec ut lavet ; post deinde. 
Quod jussi ei ante bibere, & quantum imperavi, 
Date : mox ego hue revertor. 

Madame Dacier's remark upon these lines is much to our purpose. 
3. Nunc prtmumfac, isthac ut lavet. La 'premier chose que vous devez 
/aire c^est de la baigner. C'etoit la coutume en Grece, des qu'une 
femme etoit accouchee on la mettoit au bain. II y a sur cela un passage 
remarquable dans Callimaque, & un autre dans Lucien. 

The passage in Callimachus here referred to proves that women 
bathed in a running stream immediately after delivery. 

'Etvda a cTrel fiifjTTjp fieyoKuv direOrJKaro koXttuv, 

AvTLKa 8i^r]T0 poov SSaros, cj Ke tokoio 

Atifiara xur^(io•atro, rebv 8' evl xp^'^^- Xoecraai. 

Hie te postquam mater magno deposuit ex utero, 
Statim quaerebat rivum aquae, quo partus sui 
Sordes ablueret, tuumque corpus purgaret. 

Some of the most particular and best attested modern accounts of 
this custom, are the following. 

' The Americans that inhabit the Isthmus of Darien, make no 
difficulty of plunging into cold water when they are in a sweat, to cool 



ii6 CHARLES WHITE 

puerperal fever is actually present, this practice might 
with safe[42]ty or probability of success be employed, 
I shall not venture to determine. In an [43] obstinate 
constipation of the bowels, attended with extreme 
pain, considerable [44] fever, and immediate danger. 
Dr. Stevenson informs us that a cure was obtained 
chiefly by dashing cold water upon the lower extremi- 
ties up as high as the pubes, and plunging the feet into 
cold water, after the warm bath had failed. Edin. 
Med, Ejf, vol. VI. 393. What analogy this case may 
have to the pu[45]erperal fever, I leave my readers to 
judge. 

themselves ; likewise the mothers with their children bathe in cold 
water immediately after they are brought to bed. This is certain, 
that they never receive any damage from this custom ; whereas, on the 
contrary, many women suffer greatly in these parts from too delicate 
a regimen.' 

Brookes's Nat. Hist., Vol. i, p. 175. 

The following quotation is taken from Wafer's new Voyage and 
Description of the Isthmus of America, price 2s., printed 1704, now 
added to Dampier's Voyage, Vol. Ill, p. 360. 

* When a woman is delivered of a child, another woman takes it 
in her arms within half an hour or less after it is born, and takes the 
lying-in woman upon her back, and goes with both of them into the 
river and washes them there.' 

Wafer, p. 360. 

*The Brazilian women are extremely fruitful, have very easy 
labours, and rarely miscarry, for no sooner is a woman delivered, but 
she gets to the next river, and without any further help washes herself 
there.' 

Newhoff's Voyages, p. 151. 

* The Tapoyar women cut the navel string with a shell, and wash 
themselves and their children every morning and evening after delivery.' 

Id., p. 154. 

The Brazilian women are very fruitful, have easy labours, retire to 
the woods where they bring forth alone, and return after washing 
themselves and their child ; the husbands lying in bed the first 



APPENDIX 117 

Since the publication of the former edition of my 
treatise, I have received a letter from that excellent 
professor of midwifery, Dr. Young of Edinburgh, 
containing an account, well worthy the attention of 
the faculty, of the appearance of the puerperal fever 
in the lying-in ward of the infirmary of that city. 
The letter is dated 21st of Nov. 1774, and the following 
is an extract from it. 

' We had the puerperal fever in the infirmary last 
' winter. It began about the end of February, when 
' almost every woman, as soon as she was delivered, or 

twenty-four hours, and being treated as if they had endured the pains. 
Confirmed by Woods Rogers, p. 57. 

* The Californians had adopted that absurdity, which is so much 
laughed at in the accounts of Brazil, that the women after delivery, 
used immediately to go to some water and wash themselves and the 
child ; and in other particulars to observe no manner of caution, 
going to the forest for wood and food, and performing every other 
service the husband wanted.' 

Nat. y civil Hist, of California^ translated from the original 
Spanish of Miguel Venegas, a Mexican Jesuit; published 
in 1758, translat. 1759, f- ^^ ^ ^'^' N.B. The northern 
point of California is in lat. 46. 

Long, Esq., one of the judges of the admiralty, in his History 

of Jamaica, published in 1774, Vol. II, Book III, Chap, i, p. 380, 
speaking of the negroes on that part of the African continent, called 
Guinea, or Negro-Land, says, ' Their women are delivered with little 
or no labour ; they have therefore no more occasion for midwives, 
than the female Oran-outang, or any other wild animal. A woman 
brings forth her child in a quarter of an hour, goes the same day to the 
sea and washes herself. Some have been known to bring forth twins 
without a shriek or a scream, and it is seldom they are confined above 
two, or at most three days. Immediately before her labour, she is 
conducted to the sea-side or a river, followed by a number of little 
children, who throw all manner of ordure or excrement at her in her 
way, after which she is washed with great care. Without this cleanly 
ceremony, the negroes are persuaded that either the mother, the 
child, or one of the parents, will die during the period of lying-in.' 



ii8 CHARLES WHITE 

* perhaps about twenty-fours hours after, was seized 

* with it ; and all of them died, though every method 
' was tried to cure the disorder. What was singular, 
' the women were in good health before they were 
' brought to [46] bed, though some of them had been 
' long in the hospital before delivery. One woman 
' had been dismissed the ward before she was brought 

* to bed ; came into it some days after with her labour 
' upon her ; was easily delivered, and remained perfectly 
' well for twenty-four hours, when she was seized with 
' shivering and the other symptoms of the fever. I 

* caused her to be removed to another ward ; yet 
' notwithstanding all the care that was taken of her 
' she died in the same manner as the others. I must 

* inform you at the same time, that the disease did not 

* exist in the town. To account for this distemper in 

* the lying-in ward, I must acquaint you that it has 

* been a general observation, that the patients in the 

* infirmary who had undergone any considerable 
' operations, were more subject to erysipelatous 
' swellings than formerly. I found that the women 
' in the lying-in ward last year did not recover so [47] 

* well as formerly, but scarcely any of them died. It 
' was these appearances which made me think there 

* was a local infection, and determined me to shut up 
' the ward tiU it could be removed. This I did after 

* losing six women. I then washed and painted the 
' ward, caused all the bedding to be removed, and fired 
^ gun-powder at different times in the ward. I had a 
' number of chaffers filled vidth cinders, which burnt 



APPENDIX 119 

' all night ; and all the windows were opened 
' through the day. This operation lasted about a 
'fortnight, when I furnished the ward with new 
' bedding, put no curtains to the beds, and by this put 
' an entire stop to the disease. The ward was open 
' to, receive patients in a fortnight from the time it 
' was first shut up. The bodies of all the women were 
' opened, and we found exactly the same appearances 
' as are mentioned by those who have wrote upon that 
' disorder. Though the o[48]mentum was often found 
'suppurated, yet in none of them was there any 
' appearance of a gangrene.' 

Several facts of importance in the history of the 
puerperal fever are contained in this account ; particu- 
larly — that none of the women were seized with it 
before delivery, though some of them had been long 
in the house — that although the disease was so fatal 
in the infirmary, it did not exist in the town — and 
that an entire stop was put to it by thoroughly cleansing 
and new furnishing the ward, so that in a fortnight 
after it was opened again with safety for the reception 
of patients. Possibly it may be urged as an argument 
against absorption, that ' almost every woman as soon 
' as she was delivered, or perhaps, about twenty-four 
' hours after was seized with this fever.' But I 
believe this objection will not be found of any force, 
if we consider that [49] it will not be an easy matter 
to determine whether the heat, shiverings, or accelerated 
pulse, which happen in some hours after delivery, 
are symptoms of a puerperal fever, or merely the 



I20 CHARLES WHITE 

effects of the labour ; especially in an irritable habit 
of body, as these are symptoms which are frequently 
seen soon after delivery when no fever has supervened ; 
and an absorption may take place in a very few hours. 



Mr. Eli Cope, an ingenious surgeon of Leek in 
Staffordshire, who formerly lived in my house a 
considerable time as a pupil, and whose veracity may be 
depended on, has favoured me with a remarkable 
confirmation, from his own practice, of the safety and 
advantage of the method of treatment which I have 
inculcated. From an exact account of every woman 
he has delivered since he left me, amounting to 593, 
with the circumstances of their cases, he assures me that 
he has not lost one from the pu[50]erperal fever, nor 
from any other cause where he alone was concerned. 
Many praeternatural, laborious, and flooding cases had 
occurred among this number ; yet they were all 
managed according to the plan above recommended ; 
and particularly not a single patient had lain in bed 
twenty-four hours together after delivery. One 
instance that he relates of the good effects of suffering 
the shoulders to make their proper turns, in preventing 
after pains, is so remarkable, that I shall give it at 
length in his own words. 

' A farmer's wife in our neighbourhood applied to 
* me in February 1773, desiring me to attend her in 
' her labour, which she expected in a few weeks. She 



APPENDIX 121 

told me she had had six children, and had very easy 
labours ; but that she had suffered so much with 
after-pains for a fortnight, that it rendered her 
unable to leave her room at the end of six weeks. I 
attended her in a [51] natural good labour. As soon 
as the head of the child was born, I observed the 
shoulders to make their turn, having my left hand 
under the child's chin, and the right hand on the 
occiput. In the position I was determined to wait 
till a pain came, which was seventeen minutes : this 
forced the child as far as the hips. The next pain, 
which was in about two minutes, totally expelled the 
child. 

' I have since attended her, and only waited fourteen 

minutes after the head was born. She never after had 

a single after-pain, but was about her business in 

three weeks.' 

My worthy friend Mr. Aikin, whose character and 

abilities are well known to the public, and others of 

my pupils, as well as many other practitioners, have 

also favoured me with their testimony to the success 

of the several points of practice recommended in the 

foregoing treatise. 

[52]ADDITIONAL CASES 

Case XVI 

Jonathan Kershaw's wife of Haven near Greenacre 
Moor, in the parish of Oldham, about thirty years of 
age, being at the full period of gestation, had the 
misfortune on the second of July 1770, to fall upon a 



122 CHARLES WHITE 

pot vessel, which broke, cut through her cloaths, and 
made an horizontal wound in the abdomen, about a 
quarter of an inch above the navel, and about two 
inches in length. Labour pains immediately succeeded 
and she was delivered in about thirteen hours of a 
living child. I saw her in about fifty hours after the 
accident, and found that a piece of the o[53]mentum 
as large as my fist, had protruded itself through the 
wound, and lay upon the outside of the abdomen ; 
it had a very putrid appearance, discharged a bloody 
serum, and smelt very offensively. The omentum was 
wounded, and a triangular piece of pot was found 
within it. I spread it open carefully, to examine 
whether any portion of the intestines were protruded 
along with it, and being satisfied that there was not, 
I applied a ligature round it close to the abdomen, 
and then cut off all that part beyond the ligature. In 
about a fortnight the ligature came away, and in less 
than a month the wound was perfectly healed without 
the least inconvenience, and she has since had another 
living child. 

REMARK 
This case, as far as one instance will go, proves that 
the omentum in puerpe[54]ral women is not particularly 
liable to inflammation, suppuration, and mortification ; 
but in those cases where there has been that appearance 
upon dissection, it has been owing to acrid matter 
being absorbed and deposited upon it, and not to 
any original disease in the part produced by pregnancy 
or parturition. 



APPENDIX 123 

Case XVII 
In the Postscript to my account of the puerperal 
fever, I think I have sufficiently refuted the doctrine 
of those physicians, who have imagined that the 
disorder is equally common in all places. The 
following case will, I beHeve, be a sufficient answer to 
those who have maintained the opposite opinion, 
alledging that it is only generated in the metropolis, 
and never exists in other parts of the kingdom. We 
shall here see it in a [55] very malignant state, make 
its appearance in the town of Manchester. 

A B. of Manchester, a remarkably healthy woman, 
who had hitherto scarcely experienced any disorder, 
was in the beginning of her first pregnancy afflicted 
with pains in her stomach, attended with vomitings ; 
but during the last four months she was perfectly well, 
at least as free from complaints as one can be supposed 
to be in her situation. 

On the 25th of October 1772, she wras delivered of 
two children by a careful surgeon in this town, who 
conducted the labour with great propriety. Her 
labour, which continued about fifteen hours, was 
rather slow than difficult. The first-born child 
presented itself in a natural position ; the second with 
the buttocks foremost ; but, as the infant was very 
small, it was easily brought into the world in that 
posture. The placenta [56] was expelled naturally. 
For a day or two, the patient imagined she perceived 
a large lump, which seemed to roll about within her 
belly, and which she sometimes endeavoured to fix by 



124 CHARLES WHITE 

holding her hand upon it. This, however, gave her 
no pain ; and after the second day, this symptom, 
which arose from the womb's not having sufficiently 
contracted itself, entirely vanished. The lochia flowed 
plentifully, her milk was secerned in proper quantity, 
and she gave suck to her children. 

On the third day, she complained of a little pain in 
her belly ; and as she had not had a stool since her 
delivery, a glyster and some opening medicines were 
administered, which procured a plentiful evacuation ; 
and in the evening she took an opiate. 

On the fourth day she was pretty easy. 

[57] On the fifth she complained of pain and soreness 
in the lower part of the abdomen, which grew so 
troublesome, that it was thought necessary to repeat 
the opiate ; and some small doses of emetic tartar 
were administered, which puked her, procured a few 
stools, and brought on a gentle perspiration. Her 
lochia and milk began to diminish, she got out of bed 
for the first time in the evening, but was so sick that 
she could not bear up, and was immediately put into 
bed again. Her pulse was very quick, and her disorder 
seemed to be increasing. 

In the morning and evening of the sixth, she took 
a little rhubarb and nitre. 

On the ninth day I was desired to visit her by the 
gentleman who had delivered her. I was informed 
that she had seldom sat up in bed, and only once been 
out of it. The house was situated in the most crowded 
part of the town. The room [58] she lay in was 



APPENDIX 125 

about six yards in length, and five in breadth ; but 
it was very low, its height not exceeding six feet and 
a half. It was not, however, remarkably hot, though 
a fire, at which the victuals of the family were dressed, 
was kept constantly in it : the fire was at a considerable 
distance from the bed. The nurse and both children 
lay in the same bed with the patient, and her husband 
lay in another in the same room. The surgeon who 
was employed, very prudently ordered the door, and 
sometimes a window, to be opened in the day-time ; 
but his directions were not complied with, and when 
he had himself opened them, they were immediately 
shut upon his leaving the chamber. She had every 
day wine, though in no great quantity, put into her 
gruel, and no acids were given her. She complained 
of frequent motions to make water ; of pain, soreness, 
tension, and swelling in the lower part of the abdomen. 
Upon [59] examining the parts with the greatest 
attention, I found that her complaints were confined 
to the region of the uterus and bladder ; and that the 
swelling was perfectly circumscribed ; and that neither 
the pain, the swelling, nor the soreness, extended 
beyond the half way from the pubis to the navel ; or 
was there at that time any reason to apprehend, either 
from the nature of the symptoms, or the touch, 
that there was any inflammation, or other disorder, 
either in the stomach, omentum, or intestines, if we 
except a gentle soreness with which it was affected. 
The gentleman who was employed for her, introduced 
a catheter into her bladder, that he might discover 



126 CHARLES WHITE 

whether it was distended with water ; but it did not 
contain above three or four spoonfuls. Upon pressing 
the catheter against the fundus of the bladder, she 
complained that there was the seat of [60] her disorder. 
She was thirsty, but her tongue was very little altered 
from its natural state ; it having neither a white nor a 
brown fur upon it. She had very little milk, and her 
lochia were reduced to a small sanious discharge. 
She had neither rigors, vomitings, nor eruptions. 
The heat of her skin, and the excessive quickness of her 
pulse, which beat no less than i6o times in a minute, 
were her only alarming symptoms. I several times 
examined her pulse by a stop watch, when she was 
neither fluttered nor in great pain, and constantly 
found them the same. From this single circumstance, 
upon my first visit I prognosticated that she could not 
recover. Small doses of emetic tartar, which gently 
puked her, were administered several times to day. 
Butter-milk possets and butter -milk were ordered for 
her common drink, and in the evening she got out of 
bed. 

[61] On the loth her pulse beat only 128 times in 
a minute, her belly was rather softer, she had several 
stools, and seemed no worse in any respect. On the 
nth, the lower part of the belly about the uterus was 
softer, but the whole abdomen began to swell. Her 
pulse beat 160 times in a minute. She had many 
stools ; and salt of wormwood, with the juice of 
lemons, was frequently given in the act of fermentation. 
Upon the 12th the whole abdomen was much distended. 



APPENDIX 127 

and the pain, which now extended itself to her sides, 
was so violent, that her cries alarmed the neighbours. 
That we might procure her a little ease, we were 
obliged to apply an anodyne fomentation to her belly, 
and to give her opiates mixed with ipecacuanha. She 
had a great many stools, and her tongue had a white 
fur upon it. 

Her looseness stopped, and she had [62] not much 
pain, upon the 13th, but her belly was greatly distended. 
Her pulse was so quick as hardly to be counted. Her 
extremities were cold. She retained her senses to the 
very last moment ; and expired about nine o'clock in 
the evening. 

DISSECTION 

The surgeon who attended her, opened her body 
the next day, in the presence of another surgeon, and 
two young gentlemen of the profession. My being 
called to a distance prevented my attendance ; but 
he told me that the appearances were exactly corres- 
pondent to those which he had observed in London, 
in subjects who had died of the true malignant 
puerperal fever.^ The omen[63]tum was almost wholly 

I. The great variety of the appearances on dissection, and the 
little certainty as yet obtained from it with regard to the principal seat 
of the disease, are fully shewn in the following passage. 

' In about forty women whom I have had opportunity of inspecting, 
all or some of the following appearances have been observed. The 
uterus or its appendages were in a state of inflammation and sometimes 
mortified. The os uteri, and that part of the uterus to which the 
placenta had adhered, had generally a morbid appearance. Small 
abscesses were formed in the substance of the uterus, or in the cellular 
membrane which connects it to the adjacent parts. The bladder was 



128 CHARLES WHITE 

dissolved : detached pieces floated in the abdomen, 
which contained almost three pints of thick purulent 
matter, and of serous fluid. The stomach and 
intestines were much inflated, and the intestines were 
[64] glued to each other, and to the peritonaeum ; 
but in such a manner that they might be pulled 
asunder without tearing their coats. They appeared 
to be pasted together by a kind of gluten ; and 
inflammation seemed not to have been in the least 
the cause of their adhesion. Some of the smaller 
vessels seemed to be a little turgid with blood. He did 
not any where observe the appearances of inflammation 
or mortification. The left ovary was rather larger 
than the other, but perfectly sound. The womb, 
which not contracted to its usual size, was capable of 
receiving an hen's egg ; and upon cutting it open, 
its sides were found to be three-quarters of an inch 
in thickness. The inward coat appeared to be entirely 
black, as if in a state of mortification ; but upon 
wiping it clean, the blackness was found to be nothing 
more than the putrid lochia and deciduous membrane, 

inflamed. The omentum was very thin, irregularly spread, and in a state 
of inflammation. The intestines were inflamed, chiefly in the 
peritonaeal coat, adhered in many places, and were much inflated. 
Inflammatory exsudations, and serum extravasated in the cavity of the 
abdomen, have been found in various quantities ; but these were in 
a less degree when the patient had laboured under a long continued 
purging. Large flakes of coagulable lymph were found in the cavity 
of the abdomen, which have been often mistaken for dissolved portions 
of omentum. It must indeed be acknowledged, that the information, 
acquired in this search, has not been equal to the care or to the assiduity 
with which it has been made.' 

Denman on the Puerperal Fever. 
Second Edit., p. 29 and 30. 



APPENDIX 129 

which had covered the whole inside of the uterus. 
[65] There was not the least appearance of laceration, 
or of any other external injury. 

REMARKS 

The situation of the patient's apartment, which 

was in the closest part of the town ; the remarkable 

lowness of the room ; the vitiated state of the air from 

the breath of so many persons ; the horizontal position 

of the patient for many days together ; her complaint, 

at first, confined to the lower part of the abdomen, 

and afterwards gradually rising higher ; the quickness 

of her pulse in the beginning of the disease, and its 

beating four days before death 160 times in a minute ; 

are circumstances which merit the utmost attention. 

So quick a pulse is seldom produced by inflammation, 

when unattended with depositions or absorptions of 

matter, though accompanied with the most violent 

pain. The most inflammatory gout, when pro-[66] 

ductive of the most excruciating torture ; the most 

violent paroxysms of the stone, either in the kidneys 

or the bladder, or in the passage from one of them to 

the other ; the excessive and almost intolerable torture 

arising from a gall stone passing through the ducts ; 

the pain and inflammation in the pleurisy, the iliac 

passion, or the cholera morbus ;^ nay even those arising 

I. * The first attack of this fever is sometimes so violent, that in 
many respects, it resembles the cholera morbus ; for the pain, sickness, 
and burning heat in the stomach and bowels, are almost the same ; and 
the bile, in great profusion, is discharged upwards and downwards ; 
though in the first, the pulse is more quick and weak.^ 

Leake, p. 47. 
I 



130 CHARLES WHITE 

from the strangulation of the intestines, or omentum, 
or from any of the principal operations in surgery, as 
lithotomy, amputation, &c. (except where a mortifi- 
cation is come on and the patient is in the agonies of 
death) do not occasion so rapid a pulsation. A pulse 
so excessively quick is seldom pro[67]duced by pain, 
though accompanied by inflammation. A quick pulse 
is however the pathogonomonic symptom of all 
absorptions, whether they be produced by ulcers in 
the lungs, in the joints, or in any other part of the 
body ; though unattended by pain or inflammation. 
I have known an excessive acceleration of the pulse 
proceed from a small wound in the joint of the knee, 
attended with absorption, where the patient was 
perfectly well immediately before the accident. 



Case XVIII 

Being called to Ashton-under-Line (a town in this 
neighbourhood) to see a patient, as I was talking with 
Mr. Greaves, an ingenious young surgeon of that 
place, a corpse with a white sheet thrown over the coflin 
was carrying through the streets to be buried. Con- 
cluding from this circumstance, that it was a woman 
who had died in child[68] bed, I enquired into the 
nature of her disorder. He informed me she died of 
a puerperal fever. Her name was Ann Leek, a poor 
woman, about 35 years of age. The particulars were 
as follow. He was called to her in the middle of the 



APPENDIX 131 

eighth month of her third pregnancy, for a flooding 
which was so violent that the blood ran through not 
only the bed, but even the floor, into the room below ; 
but by taking plentifully of the bark, she recovered 
and went to her full time, when she was delivered by 
a midwife on the i6th of November, 1772, and had 
a very easy natural labour. 

He heard no more of her till the 23 d, when he 
found her with a very quick pulse, brown dry tongue, 
and delirious. She had a great number of petechiae ; 
and her stools, which came from her involuntarily, 
were very offensive. Her friends informed him 
that [69] she was seized a few days after her delivery 
with a shivering fit, succeeded by vomiting and loose- 
ness, and complained much of her belly. She died 
upon the 24th, being the ninth day from her delivery. 

Upon enquiring into the most probable causes of her 
death, Mr. Greaves informed me that the room she lay 
in was intolerably offensive, owing to a vessel containing 
about four gallons, kept there as a reservoir for all the 
urine of the family, which was emptied once a week 
for the use of the dyers, but was never cleaned. 

Case XIX 

About five years ago, Mrs. W , who was then 

twenty one years of age, was delivered of her first 
child, as she sat upon the knee of an assistant. [70] She 
was confined to her bed till the fifth day after her 
delivery, and during this time scarcely ever sat up. 



132 CHARLES WHITE 

On the fifth and sixth days she was raised, that her bed 
might be made, but was not able to continue up longer 
than was necessary for that purpose ; and she was 
afterwards confined to her bed eight successive days 
without getting out of it. During this time she was 
attacked by a violent fever, attended with mihary 
eruptions, both of the white and red kind. Of this 
fever she perfectly recovered ; but upon returning to 
her usual exercise, she was seized with a prolapsus 
vagincBy which, except in the latter end of her 
pregnancies, hath ever since continued. 

On the seventh of January, 1773, she was delivered, 
by a gentleman of this town, of her third child, as she sat 
upon the knee of an assistant. He informed me that, as 
soon as the child was born, [71] he pulled gently at the 
navel string ; and that a smart pain came on, which totally 
inverted the uterus, forcing it down, to the size of his 
hand, through the labia, with the placenta still 
adhering to its fundus. The nature of her case 
immediately struck him ; but to be more perfectly 
satisfied, after making an apology for so uncommon a 
request, he called for a candle, and found he was not 
mistaken in his conjecture. He carefully separated 
the placenta from the uterus with his fingers, and 
attempted, but in vain, to restore the womb to its 
pristine state. He was only able to push it up into the 
vagina. In this situation she was put to bed, and he 
came to me to desire I would visit her along with him. 
In about an hour after this I saw her, and found the 
uterus about the size of a large new-born infant's head, 



APPENDIX 133 

totally inverted, and lying within the vagina. She was 
in great pain, had lost much blood, was very faint, and 
no pulse could be felt [72] in either arm. I attempted 
to return the uterus to its place by pushing at its fundus ; 
but as this was attended with great pain, brought 
on a violent forcing down, and was accompanied with 
much loss of blood, I for a while desisted, from an 
apprehension that she might die under my hands. 
I now prescribed her an opiate, with a few drops of 
vitriolic elixir. 

Upon further consideration of her case, I was of 
opinion that the body of the uterus was too large to 
pass through the neck, which was a little contracted ; 
therefore in a few minutes after she had taken the 
opiate and vitriolic drops, without waiting for their 
effects, I hastened to reduce it by the following mode of 
practice, which I believe to be entirely new, and which 
had never before occurred to me. I grasped the body 
of it in my hand, and held it there for some time, in 
order to lessen its bulk by compression. [73] As I very 
soon perceived that it began to diminish, I persevered ; 
and soon after made another attempt to reduce it, by 
thrusting at its fundus. It began to give way. 
I continued the force till I had perfectly returned 
it, and had insinuated my hand into its body. I now 
withdrew my hand a little and endeavoured to close 
the OS uteri by assisting it in its contraction with my 
fingers. It was no sooner reduced, than the pulse in 
her wrist began to beat. She recovered as fast as we 
could wish, and without a single alarming circumstance. 



134 CHARLES WHITE 

REMARKS 

Had not the idea occurred to me of its being 
practicable to diminish the uterus by compression, 
I am satisfied I should not have been able to have 
replaced it ; and though my first attempt to reduce it 
without compression distressed my patient greatly, yet 
the method [74] I afterwards pursued, seemed to be 
attended with little pain. 

Several circumstances might probably contribute to 
this accident ; the prolapsus vagince^ with which the 
patient had been sometime troubled — the position she 
was in at the time of delivery — the sudden delivery of 
the child — the adhesion of the placenta exactly to the 
bottom of the uterus — the insertion of the funis in the 
very centre of the placenta, and the pulling at the 
navel string too soon after the birth, before the uterus 
had sufficiently contracted itself, and whilst the 
woman was nearly in an upright situation. 

Cases of inverted uteri are not very frequent ; and 
the recoveries of patients who have met with such 
accidents have been extremely uncommon. The 
reason they so seldom occur, may probably with 
justice be attributed to the [75] necessity of so many 
concurring circumstances. The proper means of 
returning the inverted uterus not being before 
discovered, and the want of speedy assistance, may be 
the reasons why so few have recovered. I know but of 
two written instances of recovery after a total inversion ; 
one is mentioned by Ruysch, Obs. lo, where the wife 



APPENDIX 135 

ol a certain Jew was the patient, the other by Dr. Harvie 
in his Practical Directions, p. 21. Le Motte, indeed, 
1. 5. c. 10. Obs. 384, mentions another case in which the 
patient recovered, but in this he does not seem to think 
that there was a total inversion. 

My father informed me that he was many years ago 
sent for to a woman in this situation, about ten miles 
from hence ; but she died before his arrival. She had 
been delivered as she sat upon the knee of an assistant, 
and the midwife had by pulling at the navel string 
too soon after [76] the delivery, totally inverted the 
uterus. About eight years ago I was sent for myself, 
and in a case exactly similar. The woman lived 
about a mile from hence, and as I was then from home, 
Mr. Aikin, at that time my pupil, went in my stead. 
The patient died as he entered the chamber. He 
found the inverted uterus beyond the labia, and the 
placenta still adhering. 

Those who would vdsh to see more histories of these 
truly alarming cases, may consult Ruysch, Obs. 10 
and 26 ; Mauriceau, Obs. 355 and 685 ; Giffard's 
Cases in Midwifery, case 176, p. 421 ; Chapman, 
case 29. p. 197 ; La Motte, Lib. 5, chap. 10, Obs. 384 ; 
Smellie's Works, vol. 3, Collection 44, cases 3 and 4, 
p. 494 and 495 ; and Dr. Hunter's MSS. Lectures on 
the Gravid Uterus. 

This case likev^se helps to prove that [77] prolapsuses 
of the vagina, or bearings down, as they are commonly 
called, are not occasioned by too early getting out of 
bed after delivery ; as this woman in her first lying-in 



136 CHARLES WHITE 

never got out of bed till the fifth day, and scarcely ever 
sat up in it during that time ; nay she was totally 
confined to her bed fourteen days, except on the fifth 
and sixth days that she w^as raised, whilst her bed was 
made ; and yet when she returned to her usual exercises, 
she perceived the prolapsus vagince. It must therefore 
have been owing to some other cause, probably to the 
upright position during labour, and the too hasty 
delivery of the shoulders. 



Case XX 

Hannah Norbury of Blakely, a small village, about 
three miles from Manchester, aged 27, was delivered of 
her first child, by a midwife [78] in the neighbourhood, 
on the 4th of March 1773, as she sat upon the knee 
of an assistant. She had an easy natural labour, and 
the placenta came away without difficulty. She was 
of a corpulent habit, but had enjoyed pretty good 
health, except a trifling cough which she had been 
troubled with for about eighteen months ; and at the 
latter end of her pregnancy she had been for the most 
part costive. During her labour she complained of 
the head ache which continued afterwards. She was 
kept in a continual sweat and never once sat up in bed, 
till the third day in the afternoon, when she got out 
of it, for a little while ; the child was applied to her 
breasts this day for the first time, the lochia were 
almost stopped, and she had a shivering fit in the 



APPENDIX 137 

evening succeeded by a burning and a sweating fit. 
On the fourth day her breasts were a little troublesome, 
but by rubbing with a little oil they grew easy. On 
[79] the 5th. had another shivering fit. On the 6th. 
had a stool which was the first she had had since the day 
before her delivery. On the 8th. she was seized with 
a bilious vomiting, and a looseness ; her urine was high 
coloured and muddy, and she coughed much in the 
night. She had a delirium, but her husband observed 
that it was only at such times when she lay upon her 
back, but that when she lay upon her side she was 
quite free from it. 

On the 9th, she remained much in the same state. 
In the evening I was applied to, and ordered her 
tartar emetic and calx of antimony, which puked her, 
and eased her stomach and bowels. 

On the loth, I saw her for the first time. Her 
pulse were small and beat 176 strokes in a minute ; her 
voice fault ered ; she was sometimes de[80]lirious 
her eyes were red and looked wild, and she said her 
head ached. She did not make any complaint of her 
belly ; but when I laid my hand upon it below the 
navel, in any part of the hypogastric region, it was so 
exceedingly tender that she could scarce bear me to 
touch it, but about the navel, and above it, she made 
not the least complaint though I pressed ever so hard. 
Her bed was placed within half-a-yard of the fire ; and 
her friends informed me that she had sweated much 
since her delivery, that her only food had been meal or 
groat gruel, given warm with a little wine in it, and once 



138 CHARLES WHITE 

it was mixed with a small quantity of malt liquor. 
I ordered her the salt of wormwood and juice of lemons 
in the act of effervescence, and gave her leave to drink 
butter-milk posset, which she had before asked for, 
but it had been denied. The lochia were stopped 
except a little brown water. She had not much milk, 
but the child conti[8l]nued to suck her. On the nth, 
I saw her again : her pulse were so small and quick 
as not to be counted, she had convulsive spasms, and 
was not able to speak or take any medicines. She had 
only one stool this day, and no vomiting. 

On the 1 2th, stools and urine came from her 
involuntarily, and she died in the evening. 



REMARKS 

I MUST observe that the room in which this woman 
lay had no door to it, nor were there any curtains to 
the bed ; therefore I believe there could not be much 
putrid air except what was confined under the bed 
cloaths. The mismanagement chiefly consisted in 
keeping her in an horizontal position, for three days 
successively, without once sitting up in bed — in 
permitting her to be seven days without a stool — in 
her [82] being too much heated by the fire, too many 
bed cloaths, and drinking warm liquids with wine in 
them ; in sweating too much, and not being allowed 
any cooling acescent liquors. 



APPENDIX 139 

DISSECTION 

Upon opening the abdomen about fourteen hours 
after death, there was not the least disagreeable 
smell : the omentum was large, perfectly sound, 
spread regularly over the intestines, and of a natural 
colour, except a little of the lower edge which was 
not so bright a yellow. The intestines shewed not the 
least sign of inflammation, and were perfectly sound : 
they were not glued to one another, nor was there any 
matter or watery fluid floating in the cavity of the 
abdomen. The uterus was something larger than my 
fist, of a natural colour but flaccid ; upon cutting it 
open the inside ap[83]peared black, but I easily wiped 
off the blackness, which seemed to be nothing more than 
some remains of the spongy chorion and some particles 
of blood. Her friends being very averse to any 
further examination, I was obliged to desist. 

Case XXI 

Ann Worthington, aged twenty-six, was delivered 
of her first child, by a gentleman of pretty considerable 
practice, on Friday the i6th of June, 1775, about noon. 
He informed me that in attempting to bring away the 
placenta, the navel string broke : he afterwards tried 
to extract it by the manual operation, but found the 
uterus so contracted in the middle like an hour-glass, 
that he thought it most prudent [84] to desist for the 
present, and gave her an opiate. He desired I might 



140 CHARLES WHITE 

be called in, and I saw her about five hours after her 
delivery. I found she had flooded much ; her pulse 
were small, and she was very pale with the loss of 
blood ; but the flooding had now much abated, and she 
seemed tolerably easy. I therefore did not examine 
her, nor order any thing, but to continue to take an 
acid julep, which had been prescribed her ; to drink 
coohng subacid liquors ; to keep the doors and windows 
open, as the weather was excessively hot ; and to sit 
up in bed as often as possible, if she did not flood. 
The next morning she got out of bed, which was made 
and her linen changed, and a glyster was injected. 

In about 30 hours after delivery, as there was no 
sign of the placenta coming away, and the weather 
was remarkably hot, I was afraid of its growing 
[85] putrid, and producing a putrid fever ; I therefore 
examined her for the first time, in order to assist in 
bringing it away ; but found that the contraction still 
remained, and the placenta was quite out of my reach 
without using violence. The lochia were in proper 
quantities, and not offensive. 

On the second night, she had a severe shivering fit, 
succeeded by a hot one, and terminated by a sweat. 
In the morning she took a vomit of ipecacuanha in 
powder, and got up out of bed. 

On the'^ third day had another rigor, got out of bed 
again in the evening, and staid up an hour. Being 
costive, and complaining much of her head, and her 
belly being swelled and tender, with her pulse 120, 
an aperient mixture was prescribed, but that not 



APPENDIX 141 

operating, she took two grains of calomel, and a quarter 
of [86] a grain of tart. emet. which gave her several 
stools, and omitted the mixture. 

The next day being the fourth, when the lochia 
grew very offensive, warm water^ was injected per 
vaginam ; she took antimonial powders, got out of bed 
tvidce a day, staid up at least an hour every time, and 
often sat up in bed. 

On the fifth day had another rigor : took salt 
of wormwood and juice of lemons in the act of 
effervescence every three hours ; took every day great 
quantities of butter-milk, oranges and lemons, and the 
doors and windows were kept constantly open. 

[87] On the sixth day she got out of bed three times, 
staying up an hour and half each time ; continued the 
neutral mixture, and the antimonial powders, which 
kept the intestinal canal sufficiently open, having 
several loose stools every day. 

On the seventh night a few pains came on, and she 
parted vdth the placenta, which was very putrid, except 
one part, which seemed not to have been long separated 
from the uterus. 

On the eighth day she was much better. On the 
tenth a diarrhoea came on, which on the eleventh was 
very severe ; she therefore took a grain of ipecacuanha, 

I. In the puerperal fever whenever the lochia are offensive, warm 
water should be frequently injected into the uterus by means of a syringe 
which has a thick syphon and a little curved ; and I am inclined to 
think that such injections would be very serviceable in all puerperal 
fevers, if properly performed. 



142 CHARLES WHITE 

and a few grains of rhubarb, which puked her, and her 
looseness abated. 

On the twelfth a slight preparation of the bark was 
ordered ; and on the [88] thirteenth^ she said she had 
no complaints, except too much milk in her breasts ; 
she kept out of bed most of the day. From that 
time she perfectly recovered. 

I. In all the cases where I have mentioned the number of days 
from delivery, it must be understood that the day of delivery is included. 
I thought it necessary to take notice of this circumstance, as I find some 
Authors observe a contrary method. 



THE END 



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